Position statement: Somatic symptom and related disorders: Guidance on assessment and management for paediatric health care providers

SNT Gatchaman

SNT Gatchaman

Senior Member (Voting Rights)
Staff member
Somatic symptom and related disorders: Guidance on assessment and management for paediatric health care providers
Canadian Paediatric Society

Members: Anne Kawamura MD (Chair), Johanne Harvey MD (Board Representative), Natasha Saunders MD, Megan Thomas MBCHB, Scott McLeod MD, Ripudaman Minhas MD, Alexandra Nieuwesteeg MD (Resident Member)
Liaisons: Olivia MacLeod MD (Canadian Academy of Child and Adolescent Psychiatry), Angela Orsino MD (CPS Developmental Paediatrics Section), Leigh Wincott MD (CPS Mental Health Section)
Author(s): Natasha Ruth Saunders MD MSc, Anne Kawamura MD, Olivia MacLeod MD, Alexandra Nieuwesteeg MD, Claire De Souza MD

ABSTRACT
Somatic symptom and related disorders (SSRDs) pose significant challenges in paediatric health care due to their impacts on child and adolescent well-being, functioning, and family systems. This statement offers comprehensive guidance to health care providers on the assessment and management of SSRDs as well as communication strategies for clinical encounters.

Specific SSRD diagnoses are outlined along with common clinical presentations and recommended approaches to medical investigations and patient/family communication early in the diagnostic journey. Evidence-based treatments for SSRDs once a diagnosis has been established are delineated. Psychoeducational approaches that help to shift the onus of care from unnecessary medical testing and procedures, thereby shortening the diagnostic journey, and promote more functional, rehabilitative care therapies, are reviewed. Specific strategies to support patients and their families and validate their perspectives are outlined.

ABBREVIATIONS
EDS, Ehlers-Danlos syndrome; FNSD, functional neurologic symptom disorder; IBS, irritable bowel syndrome; PNES, psychogenic non-epileptiform seizures; POTS, postural orthostatic tachycardia; SSRD, somatic symptom and related disorder
 
Somatization describes the experience whereby emotions, either positive (e.g., excitement) or negative (e.g., worry), and thoughts are expressed as physical signs or symptoms. Somatization is a normal and involuntary physical response to an emotional stimulus or stressor that all people experience. For example, signs of somatization may include axillary sweating when nervous, pupillary dilatation when fearful, or syncope when surprised. Symptoms of somatization can include abdominal pain when feeling anxious, or fatigue when feeling overwhelmed. Somatization is considered part of a disorder when these bodily signs or symptoms cause significant distress or impairment in daily life. Such signs and symptoms of an SSRD may occur as an isolated disorder but may also co-occur alongside another medical condition.
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According to the DSM-5 -TR[4], SSRDs comprise a cluster of five specific disorders that include: 1) somatic symptom disorder, 2) functional neurological symptom disorder (FNSD or conversion disorder), 3) illness anxiety disorder, 4) psychological factors affecting other medical conditions, and 5) factitious disorder.
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Children and adolescents with SSRDs present with non-specific signs and symptoms across the spectrum of general paediatrics (e.g., brain fog, fatigue, dizziness, joint pain, abdominal pain, hypermobility) and subspecialty paediatric areas (e.g., seizures and sensory changes (neurology), nausea and dysphagia (gastroenterology), orthostatic intolerance (cardiology), joint pain (rheumatology), and anorexia or pelvic pain (adolescent medicine)). Patients may also present with questions about or self-diagnoses of disorders that have similar common symptoms and multi-systemic presentations, including: 1) postural orthostatic tachycardia, 2) post-COVID-19 condition, 3) chronic Lyme disease, and 4) Ehlers-Danlos syndrome.
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As part of their diagnostic odyssey, the families of children or adolescents with SSRDs are often told what their child does not have (e.g., “This is not cancer, celiac disease, or Ehlers-Danlos syndrome”). Most patients hear much less about what clinicians think they do have. Because it can be difficult to talk about an SSRD diagnosis, clinicians sometimes avoid using the terms “somatization” or “mental health disorder”. But by not giving such a diagnosis when present or suspected, the family’s confusion over what is going on is perpetuated. Further, when a diagnosis of an SSRD has not been given, this prevents them from receiving evidence-based psychoeducation, rehabilitation, and psychotherapy.
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Explain the mind-body connection and normalize somatization. Offer descriptions of the physiology of stress, the role of neurotransmitters (e.g., serotonin receptors in both the brain and the gut), and for FNSD, describe the different brain regions involved (i.e., amygdala, prefrontal cortex, motor cortex). Emphasize that symptoms may be understood as a problem with ‘software’ rather than ‘hardware’. Sample scripts that clinicians can use for psychoeducation are available.
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The most widely available psychotherapeutic modality for children and adolescents with SSRDs is cognitive behaviour therapy. There is also emerging evidence for acceptance and commitment therapy, psychodynamic therapy, and emotion-focused family therapy for treating SSRDs. Caregiver coaching includes teaching validation techniques, supporting coping strategies and symptom management, and focusing on individual strengths and abilities despite symptoms.
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O M G

particularly on the transparent admitting of the nonsense fairy tales about stress response

it’s like the heady days of selling Prozac ‘cos people need their brain chemistry changed’


Ahhh now I’m thinking back to that spiel and who it was successful for I’m now realising where the fervour is coming from
 
Telling a child that their emotions are causing serious chronic symptoms is child abuse, unless it was actually true.

It sets these children up for years of feeling like a failure when they fail again and again to somehow cure themselves, and it distorts their perception of reality when they are told that something is going on inside their mind that isn't actually happening.

They should focus on helping patients feel good and manage daily life as best as possible without postulating hidden unfalsifiable emotional causes of illness.
 
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The enshittification of health care and medicine continues unopposed. In fact, met with applause and celebratory laughter.

When you think about it, this is natural. Our entire civilization is enshittifying, so why would medicine escape this? In fact, it's going at it faster and more committed than any other institution.

Right alongside a historic rise in the very illnesses they misrepresent. At the same time as this rise is leading to backlash from governments who enable this rise, but choose instead to harm twice the people they fail. At the tail end of completing a merger with alternative medicine, leaving basically no separation between either.

All leaving no institution worth trusting about anything. Well, maybe engineering, as long as they stick to engineering. At least that stuff works reliably. It's so awful.

They even explicit describe and embrace pseudoscience, the process of explaining made-up models using the tools and language of science:
Explain the mind-body connection and normalize somatization. Offer descriptions of the physiology of stress, the role of neurotransmitters (e.g., serotonin receptors in both the brain and the gut), and for FNSD, describe the different brain regions involved (i.e., amygdala, prefrontal cortex, motor cortex). Emphasize that symptoms may be understood as a problem with ‘software’ rather than ‘hardware’. Sample scripts that clinicians can use for psychoeducation are available.
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Expertise is dead. It never stood a chance against beliefs. In the end, it's either technology or beliefs, and beliefs always matter more unless you can make more money with technology. We are actually worse than the satirical civilization that believes in astrology depicted in The Orville. So much dumber in every way, it's seriously embarrassing.
 
Hoopoe said:
Telling a child that their emotions are causing serious chronic symptoms is child abuse, unless it was actually true.

It sets these children up for years of feeling like a failure when they fail again and again to somehow cure themselves, and it distorts their perception of reality when they are told that something is going on inside their mind that isn't actually happening.

They should focus on helping patients feel good and manage daily life as best as possible without postulating hidden unfalsifiable emotional causes of illness.
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It also breeds intense distrust in experts, authorities, even parents. With good reasons. This is so deeply impactful and harmful, it actually creates the perfect conditions for abuse and trauma. Given how widespread chronic illness is becoming, how stretched thin health care services are, this will only amplify as it becomes first-line bullshit care. It will raise a generation who despises the society they grew in, unworthy of being trusted for anything.

The death of expertise leads to the death civilized society. Not that we've ever had much of that.
 
The role of rehabilitation for treating SSRDs lacks high quality, evidence-based studies[44][45], but the chronic pain literature [46][47] makes it clear that a multi-modal approach, including rehabilitation services, supports recovery.
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"We have a lot of theories, but not a lot of evidence".

They assert plainly that there is evidence while they admit there is no evidence, and it's not even true for chronic pain, where the situation is just as disastrous. Absolutely insane stuff. And it doesn't just involve lying, it's nothing but lying. To the children, to the patients, to society. A giant magical con.

Even the way they talk about is explicitly "imagine a world in which X is true". It's all superfluous fluff about the potential that this may do that. Including the garbage evidence they rely on. It's all possibilities. It's as ridiculous as a government minting a trillion dollar coin and thinking they now have a trillion dollars to spend.
Rather than focusing on which diagnoses a child or adolescent does not have, share the diagnostic impression of somatic symptom disorder or functional neurological symptom disorder with the patient and family.
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"Imagine a world of diagnostic impression". Just balls out insane stuff.

And to make it clear why this is happening at all:
Dr. Saunders reported receiving personal fees from the BMJ Group, Archives of Disease in Childhood and an honorarium from the Canadian Guidelines for Post Covid-19 Condition Guideline Team outside the submitted work.
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Medicine is responsible for enabling a historic rise in illnesses they can't treat and don't believe in. And in response they do this. Evil rarely gets this banal.
 
Rather than focusing on which diagnoses a child or adolescent does not have, share the diagnostic impression of somatic symptom disorder or functional neurological symptom disorder with the patient and family.
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rvallee said:
They assert plainly that there is evidence while they admit there is no evidence, and it's not even true for chronic pain, where the situation is just as disastrous. Absolutely insane stuff. And it doesn't just involve lying, it's nothing but lying. To the children, to the patients, to society. A giant magical con.
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A brazen scam, and only getting more brazen and defiant of reality with every legit criticism made of it.

This is what I mean when I call it anti-science. Not pseudo-science, not non-science, but actively anti-science. As matter of deliberate policy and practice they are doing the exact opposite of robust science. They have mastered the form, without the content.
 
Sean said:
A brazen scam, and only getting more brazen and defiant of reality with every legit criticism made of it.

This is what I mean when I call it anti-science. Not pseudo-science, not non-science, but actively anti-science. As matter of deliberate policy and practice they are doing the exact opposite of robust science. They have mastered the form, without the content.
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A modern version of when they put ill women into asylums - except with kids?
 
Hoopoe said:
Telling a child that their emotions are causing serious chronic symptoms is child abuse, unless it was actually true.

It sets these children up for years of feeling like a failure when they fail again and again to somehow cure themselves, and it distorts their perception of reality when they are told that something is going on inside their mind that isn't actually happening.

They should focus on helping patients feel good and manage daily life as best as possible without postulating hidden unfalsifiable emotional causes of illness.
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I have been stating how children and young people are abused in this way for over 10 years now and it should come as no surprise they are going forward with the full support of the NHS England. There is a big push to get FND centers in all hospitals and I think they have achieved that, I stated a few years back on here about Addenbrooks FND encompassing all conditions. IMPARS was just the beginning.

Talking to CEO at SNEE ICB they did not understand that FND was a conversion disorder, they thought it was a function, meaning very physical condition. If they can be fooled then I guess everyone else can be? MP etc I gave a talk to SNEE a couple of weeks ago and did a PowerPoint presentation with it, to show the impact on children.

I gave another talk to 1st year medical students about the how we are misunderstood because of the lack of understanding and data and if this does not change soon we are going to be in a pickle.
I also posted above this post the link to NHS FND that states even if you have MS you can still have FND

We need the SNOMED codes to be used and for children and all to be evaluated properly with ME PEM hEDS EDS POTS and Mast cell, sort them into cohorts and start to sift through the case studies with longitudinal studies. Show the true picture through the lived experience and what we know.
 
I don't think they're suggesting EDS is a functional disorder, although as above I'm sure they would be happy to say EDS can have a co-existing functional disorder.

Patients may also present with questions about or self-diagnoses of disorders that have similar common symptoms and multi-systemic presentations, including: 1) postural orthostatic tachycardia, 2) post-COVID-19 condition, 3) chronic Lyme disease, and 4) Ehlers-Danlos syndrome. Because these conditions are commonly asked about, clinicians will benefit from an understanding of diagnostic criteria and management pathways for these four conditions.
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As part of their diagnostic odyssey, the families of children or adolescents with SSRDs are often told what their child does not have (e.g., “This is not cancer, celiac disease, or Ehlers-Danlos syndrome”).
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Referencing Multidisciplinary Approach to Treating Chronic Pain in Patients with Ehlers–Danlos Syndrome: Critically Appraised Topic (2022, Journal of Pain Research)
 
Jonathan Edwards said:
I didn't see any reference to EDS there.
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It is how they look at symptoms such as the Functional dizzyiness pain fatigue and movement you pick out how they can use this to explain classic EDS/hEDS without taking the time to look at joints, gut allergy. FND is a gatekeeping hold all hide it away causing long term harm.

The GP toolkit https://gptoolkit.ehlers-danlos.org/.

Then match up the list on the https://www.nhsinform.scot/illnesse...-spinal-cord/functional-neurological-disorder

you can see the deliberate targeting of conditions that they want to stop treating and researching
 
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SNT Gatchaman said:
Somatic symptom and related disorders: Guidance on assessment and management for paediatric health care providers
Canadian Paediatric Society

Members: Anne Kawamura MD (Chair), Johanne Harvey MD (Board Representative), Natasha Saunders MD, Megan Thomas MBCHB, Scott McLeod MD, Ripudaman Minhas MD, Alexandra Nieuwesteeg MD (Resident Member)
Liaisons: Olivia MacLeod MD (Canadian Academy of Child and Adolescent Psychiatry), Angela Orsino MD (CPS Developmental Paediatrics Section), Leigh Wincott MD (CPS Mental Health Section)
Author(s): Natasha Ruth Saunders MD MSc, Anne Kawamura MD, Olivia MacLeod MD, Alexandra Nieuwesteeg MD, Claire De Souza MD

ABSTRACT
Somatic symptom and related disorders (SSRDs) pose significant challenges in paediatric health care due to their impacts on child and adolescent well-being, functioning, and family systems. This statement offers comprehensive guidance to health care providers on the assessment and management of SSRDs as well as communication strategies for clinical encounters.

Specific SSRD diagnoses are outlined along with common clinical presentations and recommended approaches to medical investigations and patient/family communication early in the diagnostic journey. Evidence-based treatments for SSRDs once a diagnosis has been established are delineated. Psychoeducational approaches that help to shift the onus of care from unnecessary medical testing and procedures, thereby shortening the diagnostic journey, and promote more functional, rehabilitative care therapies, are reviewed. Specific strategies to support patients and their families and validate their perspectives are outlined.

ABBREVIATIONS
EDS, Ehlers-Danlos syndrome; FNSD, functional neurologic symptom disorder; IBS, irritable bowel syndrome; PNES, psychogenic non-epileptiform seizures; POTS, postural orthostatic tachycardia; SSRD, somatic symptom and related disorder
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So this is trying to introduce SSD but under the one word different name SSRD via the back door, early on, through aiming it at children ie before they could have got into the hands of a diagnostician for certain diseases heading off with a catch all list of symptoms to label them functional first ?

I have no words , what is behind all this in the world , it feels like such a sinister and organised push at the moment
 
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