No single feature on its own is diagnostic of SSRD. The index of suspicion for SSRD increases when more features are present.
| Myth 1 |
Symptoms are fake(d). Belief that symptoms are not real or intentionally produced by the child. |
| Fact |
Symptoms are real, distressing, and may be disabling. Symptoms are not faked or feigned by the child for secondary gain. |
| Myth 2 |
- Children with somatic symptoms always display la belle indifference (the beautiful indifference), where they are not concerned about symptoms that should be painful or distressing.
- Example: the child loses vision suddenly but does not appear concerned about it
|
| Fact |
La belle difference historically was a diagnostic criteria, but is no longer required for diagnosis. Some children may display incongruent or hyperbolic affect, but the level of concern regarding symptoms varies greatly and is not a factor in diagnosis. |
| Myth 3 |
SSRDs are diagnoses of exclusion or “rule-out” diagnoses.
|
| Fact |
Like any other medical or behavioral condition, we use positive diagnostic criteria to diagnose SSRD using validated historical and physical findings. |
| Myth 4 |
SSRDs cannot be diagnosed if children have organic biological illnesses.
|
| Fact |
Children often have “organic” medical and behavioral diagnoses simultaneously as SSRDs. Some medical and behavioral diagnoses may predispose a child to develop an SSRD. Many children walk two paths on their diagnostic journey, learning how to manage somatic symptoms as their medical team addresses concerns for organic disease. |
| Myth 5 |
Symptom onset must be linked to a physical or emotional trigger.
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| Fact |
Stressors or triggers historically were part of the diagnostic criteria for SSRDs. We now know that somatic symptoms may not always be linked to an identifiable stressor, though physical or emotional injuries or illnesses may be risk factors for SSRDs. Stress (in its many forms) is one of many amplifiers of somatic symptoms, and learning to function through stress is an important aspect of treatment. |
| HPI |
- Symptom Features:
- Symptoms may start suddenly
- Symptom intensity may change in a waxing/waning pattern
- Symptom flares +/- related to physical or emotional illness, injury, or stress
- Variety of somatic symptoms may emerge or shift over time
- Altered Level of Concern About Symptoms:
- Some children with SSRD may describe significant worries about being ill, concern that something is being “missed”. The degree of focus on physical symptoms may interfere with typical functioning.
- Other children with SSRD may seem to have limited concern about symptoms and their impact on function (incongruent affect).
- Withdrawal from Normal Life Activities:
- Functional decline and withdrawal from home, school, community, sports/activities
- Avoidance of physical activity, including previously preferred activities
- Exacerbating Factors:
- Strong emotional responses
- Stress (see stressors below)
- Changes in physical activity
- Symptoms Persistence Despite Medical Management:
- Continued symptoms and/or concern about being sick despite reassuring diagnostic testing
- Continued symptoms despite medication trials, procedures, or other interventions
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| Medical History |
- Comorbid significant medical diagnoses
- Significant past illnesses with no medical explanation
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| Surgical History |
- Multiple surgeries without pathologic confirmation
- History of surgery in weeks/months before onset of symptoms
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| Psychiatric History |
- Comorbid psychiatric diagnosis, specifically mood disorders including anxiety and depression
- Health or illness anxiety – fears of being sick
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| Caregiver History |
- Caregiver model for disability (e.g., immediate caregiver member with chronic illness)
- Anxiety/depression
- Anniversaries of deaths of loved ones with similar symptoms
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| Social History |
- Life Stressors:
- Changes in school, home, relationships
- Missed days of school or school avoidance
- History of abuse or neglect
- Other Adverse Childhood Events (ACES) include but aren't limited to bullying, household caregiver member with mental illness or substance abuse, parental separation, etc.
- Note:
- Some, but not all somatic symptoms start after an identifiable triggering event or injury
- Many children with SSRDs will not self-report stress
- SSRDs are often a problem in recognizing, navigating and coping with stress
- Symptoms often worsen during times of increased stress
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| Medications |
- Polypharmacy
- Describes multiple medication trials without significant improvement in symptoms
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| ROS |
- Gastrointestinal:
- Chronic abdominal pain, bloating
- Early satiety, nausea, decreased appetite
- Alternation between diarrhea and constipation
- No improvement of pain with constipation treatment
- Musculoskeletal:
- Pain > 3 months, intermittent or constant, without clear quotidian pattern, without morning stiffness
- Self-reported allodynia not following a dermatomal distribution
- Pain to a typically non-painful stimulus (e.g., reported change in clothing due to pain, pain when bathing, etc.)
- Cardiovascular:
- Severe fatigue
- Palpitations
- Persistent dizziness, lightheadedness, syncope with standing
- Exercise intolerance
- Neurological:
- Brain Fog
- Headaches – often not responsive to migraine therapies
- Sensory deficits
- Motor weakness
- Uncontrolled movements
- General:
- Sleep – trouble falling asleep, staying asleep or both
- Fatigue/low energy
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The following is a list of organ-specific historical and exam features supportive of somatization and somatic symptoms. While they are sensitive, not all signs are specific, and presence of any of these findings should not preclude thorough medical evaluation but rather cue the examiner of the possibility of somatization, regardless of other coexisting organic medical issues. No single exam finding necessarily requires referral to a specific clinic for follow-up.
| Distractibility |
- Symptoms decrease or disappear with distraction
- Conversely, symptoms increase with attention
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| Variability |
Symptoms vary in intensity, frequency may improve/worsen or appear/disappear altogether throughout the evaluation
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| Expressive/Hyperbolic affect or Increased effort |
- Displays of effort disproportionate to the task required may include grunting, grimacing, physical effort
- Sometimes termed pain/symptoms out of proportion to exam
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| Incongruent Affect |
- Pain/symptoms reported as severe, but minimal pain behaviors (e.g., grimacing, crying) witnessed
- Previously described as la belle difference
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| Impaired Function/Disability |
- Symptoms interfering with typical function or activities
- Including effects on:
- ADLs (home mobility, bathing, feeding)
- School participation
- Activities
- Social life
|
| Pain |
- Amplified Pain:
- May be focal or widespread, may be associated with allodynia, which is pain to a minor, typically non-painful stimulus (e.g., clothing, light touch, bathing)
- Pain distribution is nondermatomal
- Poorly responsive to pain medications
- 5 or More Tender Fibromyalgia Points:
- May indicate nociplastic etiology
- Axial Loading:
- Examiner pressing down on the top of the child’s head causes lower back pain
- Distracted Straight Leg Raise:
- Straight leg raise causes back pain during formal testing but not when the child is distracted
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| Weakness |
- General:
- Breakaway/Giveaway Weakness:
- When testing strength against resistance, there is a sudden or intermittent change in strength. Not to be confused with fatiguability
- Co-Contraction:
- No movement occurs at a joint because agonist and antagonist muscles are contracting simultaneously, stabilizing the joint and preventing movement
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- Functional Facial Weakness:
- Facial droop is not consistent with nerve distribution, often with isolated lower facial contraction
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- Lower Extremity Weakness:
- Hoover sign:
- Normal hip extension on weak side is triggered by formal testing of contralateral hip flexion. The idea is that muscle effort requires stabilization by contralateral antagonist muscle. There are many correlates between other LE and some UE muscle movements.
- Falls towards support:
- Falls in direction of wall/furniture and away from the weak leg
- Facial droop is not consistent with nerve distribution and with facial droop caused by contraction of muscles in lower face
- Excessive slow gait:
- Child can move legs at a normal speed, but gait speed is slowed in comparison
- Wheelchair test:
- Able to propel a wheelchair with their feet despite gait impairment. Leg movements may normalize in this setting
- Difficult postures:
- Gait pattern involves complex postures that require good balance and strength, such as bent knees or squatting
- Monoplegic leg dropping:
- Weak leg dragged like an inanimate object, without circumduction, along the surface of the floor
- Sudden knee buckling:
- Sudden knee buckling, often with each step
- Hesitance/caution:
- Gait is hesitant or cautious despite there being good balance, strength, sensation
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- Upper Extremity Weakness:
- Drift without pronation:
- Raised arm drifts down without pronation
- UE “Hoover” correlates
- Same idea as Hoover’s sign, but for upper extremities. Examples include 5th finger abduction for hand weakness and Flex/Ext sign for biceps and triceps strength.
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| Functional Tic Disorders (including TikTok Tics) |
- Sudden and explosive onset, Complex vocal tics more common (echopraxia, coprolalia) than simple vocal tics, less suppressible.
- See TikTok Tics: TS and FND Webinar
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| Abnormal Movements |
- Functional Tremor:
- Tremor entrainment test:
- Tremor frequency changes when asked to copy a different amplitude with unaffected hand or “entrains” to the examiner’s amplitude
- Tremor distractibility:
- Tremor pauses or changes in frequency during motor or cognitive task
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- Non-epileptic Events (Functional or Pseudo-Seizure):
- Forced eye closure during non-epileptic events
- Polymorphic movements: Nonrhythmic, irregular movements not consistent (ex: full body thrusting)
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| Abnormal Eye Movements |
Common manifestations include problems with convergence, darting eye movements
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| Impaired Function/Disability |
- Symptoms interfering with typical function or activities
- Including effects on:
- ADLs (e.g., home mobility, bathing, feeding)
- School participation
- Activities
- Social life
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