Somatic symptom and related disorders — formative SAQs

SAQ 1 — 13-year-old with eight months of abdominal pain, normal tests and school absence (10 marks)

A 13-year-old girl has eight months of daily abdominal pain and headache, three normal scans and a long list of normal bloods, and now attends school only two days a week. Her mother is distressed and convinced "something is being missed." She has low mood but no current self-harm plan. [1] [2]

Questions

1. State the pivotal DSM-5 / DSM-5-TR principle for diagnosing somatic symptom disorder, and outline your initial assessment including the red flags you must screen for once. (4 marks) [2]
2. Explain the mechanism to the family in validating language, and explain how you would communicate the normal results therapeutically. (3 marks) [1]
3. Outline your function-first management plan, including the goal metric and the place of analgesia. (3 marks) [4]

Model answer

Diagnosis and assessment (4). State the DSM-5-TR principle clearly: somatic symptom disorder is diagnosed on positive grounds — one or more distressing somatic symptoms plus disproportionate thoughts, feelings or behaviours, persistent typically more than six months — and the symptoms need not be medically unexplained; a separate medical illness does not exclude it. Assess by securing time alone, validating the symptom as real, taking a focused symptom history (onset, shifting sites, triggers, prior investigations) and the family's explanatory model, then a HEEADSSS-tailored psychosocial history emphasising mood, sleep, school attendance, peers, family function, bullying and life events; screen for suicidality. Screen once for red flags — weight loss or growth failure, fever/night sweats, a new or progressive neurological deficit, nocturnal symptoms waking from sleep — with a targeted panel; the normal tests already in hand make further imaging low-value without a new red flag. Quantify disability with the Functional Disability Inventory. [2] [6]

Mechanism and communicating results (3). Explain the symptom-amplification loop: a genuine bodily signal is amplified by selective attention, catastrophising ("this means damage/danger") and anxiety/arousal, then maintained by avoidance and deconditioning — the problem is altered nervous-system processing, not ongoing tissue damage, and the symptom is real. Reframe the normal tests as "reassuring because they show your body is healthy, not because nothing is wrong," explicitly avoiding "the tests are normal, so there's nothing wrong" and "it's all in your head," which dismiss and fuel the poor-reassurance spiral. [1] [5]

Management (3). Set shared FUNCTION goals — school, sleep, movement, friends — explicitly not a symptom-elimination goal. Coordinate psychology (CBT or ACT), physiotherapy (graded activity), a sleep reset, and a graded school-led return-to-school plan with education liaison. Treat comorbid low mood, with SSRI therapy considered only for a comorbid anxiety/depressive disorder under specialist guidance and monitoring. State that opioids have no routine place in a paediatric somatic presentation; simple analgesia within local guidance is at most adjunctive. [4] [2]

SAQ 2 — 12-year-old with functional weakness, and a safeguarding stem (10 marks)

Part A (5 marks): A 12-year-old presents with functional weakness of the left leg; a positive Hoover sign is present and targeted assessment excludes structural neurological disease. [7]

1. How is the diagnosis of conversion disorder (functional neurological symptom disorder) established, and outline the management. (5 marks) [7]

Part B (5 marks): Separately, a 7-year-old has recurrent, inexplicable collapse episodes and abnormal results that occur only when the mother is present; histories from the mother and stepfather are discordant, and the mother is eager for further invasive investigation. [2]

2. What is the most likely concern, and outline your immediate management. (5 marks) [2]

Model answer

Part A — Conversion disorder (5). The diagnosis is made on positive grounds — symptoms clinically incompatible with recognised neurological disease (e.g. a positive Hoover sign, internally consistent functional weakness) — after a targeted exclusion of mimics such as epilepsy, demyelination or spinal cord disease; it is not a diagnosis of exhaustion made by piling up normal scans. Validate that the symptoms are real. Management is interdisciplinary: neurology confirms the diagnosis and excludes mimics, functional physiotherapy delivers graded motor and sensory retraining, and psychology addresses thoughts, mood and the amplification loop. Comorbid anxiety and depression are common and must be actively screened for and treated. Outcomes in childhood conversion are generally good with timely functional intervention. [7] [2]

Part B — Fabricated or induced illness (5). Features only-in-carer's-presence, discordant histories and eagerness for invasive investigation suggest fabricated or induced illness — a safeguarding presentation, not a psychiatric one. Immediate management: document the history, examination and test discrepancies objectively and contemporaneously; refer to the local child-protection / multi-agency safeguarding pathway (in ANZ this is the statutory child-protection authority and paediatric child-protection team); do not confront the carer alone, which may endanger the child or compromise the investigation; and continue all clinically necessary treatment and monitoring while the process runs. Distinguish clearly from somatic symptom disorder, which is an unconscious process without deception. [2]