Pediatric emergency medicine trisk 4205 4205
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Children with psychiatric illnesses can be medically ill. Assuming a
patient’s symptoms are due to a somatic symptom disorder without
first performing an appropriate medical assessment is ill-advised.
Conversely, it is relatively rare for a pediatric patient who is given the
diagnosis of somatic symptom disorder to be subsequently
diagnosed with an underlying medical condition.
ED physicians are typically best served by maintaining their usual
“pretest probability threshold” for ordering tests, consultations, and
medical interventions based on the clinical presentation at hand.
Expanding the scope of evaluation and/or treatment to reassure
parents or to accede to their demands is often both ineffective at
calming parents and countertherapeutic for the patient.
It is important to remember that the symptoms encountered with
somatic symptom disorders are not consciously produced. Patients
are truly experiencing the symptoms and functional impairment that
they are reporting. ED clinicians should be clear that they believe
that the patient is truly suffering from the symptoms/impairment that
they are reporting, that they are not “making it up,” and that it is not
“all in their head.” Patients cannot get well if they still need to
convince people that they are sick.
Patients with somatic symptom disorders are typically in
significant distress; they are often trapped in seemingly unsolvable
dilemmas and are very much in need of appropriate and supportive
care.
Placebo trials without the family’s consent should typically be
avoided. Even when “successful,” they tend to make families feel
betrayed.
How physicians discuss psychosomatic symptoms with patients
and families can have a major impact on the clinical outcome.
Family beliefs about psychological versus medical illness typically
play a significant role in the development and perpetuation of
psychosomatic symptoms and must be addressed as part of
effective treatments.
ED physicians should frame the negative findings and lack of
need for further medical intervention as “good news.” For example,
the fact that a patient’s MRI shows that they do not have a brain
