Treating Somatic Symptoms in Young People

Somatic symptoms are real, physical symptoms that can occur in any part of the body, like dizziness, sensation loss, pain, or nausea. Unlike symptoms that indicate underlying disease or injury, somatic symptoms are primarily due to dysregulation in the autonomic nervous system. In this way, somatic symptoms often represent a problem with the way the body is functioning or working rather than a problem with the structure or tissues.

Anxiety and/or depression do not always play a role in somatic symptom development. Research has found no significant differences in mood or anxiety ratings in children with or without somatic symptoms. Coping style may play a role in somatic symptom development; a more passive/avoidant coping style is associated with somatic symptoms across multiple body systems.

Anxiety can co-occur with somatic symptoms and can certainly make them worse, or harder to treat, but the current conceptualization is that anxiety does not solely cause somatic symptoms in the first place. Historically, the term “unexplained” was used to describe symptoms that were not “explained” by a disease or injury, and because of this lack of understanding were often then attributed to emotional causes. With better research and clinical understanding, we know now that somatic symptoms are not primarily caused by emotional factors and that they are not “unexplained” at all – they just have a different reason for happening than was previously known or understood.

People with somatic symptoms may or may not be anxious. And if they are anxious, they may not connect the physical experience of somatic symptoms with the cognitive/emotional experience of anxiety, or more simply put, they may not connect their brain and body responses.

Somatic symptoms arise when there are maladaptive responses to physical sensations in the body that over-activate the sympathetic nervous system and cause the brain to over-respond to stressors. Imagine you feel nauseated the first time you give a big presentation. You may think to yourself, “Wow, this is an important presentation, I think that is why my stomach feels queasy. I’m sure it will go away once I get started,” which is an appropriate and adaptive response to a big event.

Or, you might think to yourself, “That yogurt I ate before my presentation must have been expired, I can’t believe this is happening on my big day,” which might lead to a less adaptive response, increased anxiety (regardless of whether it is identified as such), and a less positive assessment of your presentation. Then, the next time you present, you are more likely to remember how bad you felt, avoid breakfast altogether, and feel queasy again anyway just because of the anticipation of a negative outcome, not to mention working on an empty stomach!

The key here is to have a biopsychosocial formulation for somatic symptoms, rather than only a psychological formulation. An explanation that relies only on psychological factors unfortunately reinforces the “it’s all in your head” message. Modern research and understanding in the field of somatic symptoms tells us that a biopsychosocial approach better explains the experience of somatic symptoms. Somatic symptoms arise when the brain responds to physical stressors (such as dehydration, poor sleep), psychological stressors (such as fear, anger), and/or environmental stressors (such as peer relationships, community safety) and activates the sympathetic nervous system, also known as the fight or flight response. If there are multiple stressors, or one big one, the fight or flight response effectively gets “stuck” and symptoms continue to occur, as the brain and the body are not able to deactivate the sympathetic response and return to rest.

It likely does; if you have a negative body response in a situation, your natural instinct is to avoid that situation in the future. A good way to understand this is thinking about the anticipatory anxiety that comes after a food poisoning experience.

Let’s say you eat a food that makes you sick; just thinking about that food in the future is going to re-activate that sensation, and the natural way to protect yourself is to avoid that food. That works well if you’re trying to make sure you don’t eat a bad tuna sandwich twice, but not so well if you had a stomach ache before school one day and misattributed the stomach ache to food poisoning instead of the biopsychosocial stressors associated with school attendance (for example, waking up early, anxiety, and social interaction).

Education about the sympathetic nervous system response and anticipatory anxiety is the first step (the "why" behind the symptoms), followed by exposure therapy with coping skills to reduce avoidance of the feared situation and increase empowerment that a child has some tools that can help (the "how" of managing the symptoms).

Research has shown that the rates of childhood trauma are not different for people with somatic symptoms than those without. Although people with trauma often have somatic symptoms, somatic symptoms are not always caused by trauma. This is unfortunately a myth that has sustained in the field and on the internet that can be scary for families to read about. There is data that the perceived impact of negative life events can play a role in development of somatic symptoms, but that does not always mean trauma the way it is classically defined.

The first step in treatment of somatic symptoms is providing biopsychosocial education on why the symptoms are happening in the first place. Following that, typically patients benefit from increasing functioning through behavioral activation, activity pacing, and a daily schedule to begin to break the body out of the cycle of symptoms and impairment.

Next, behavioral strategies are taught, such as distraction and relaxation that can be used in the moment to manage symptoms, or prevent them in the first place. Finally, cognitive strategies, such as positive reframing and problem solving, can be used to change maladaptive approaches to symptom management. All of these strategies together are effective in retraining the brain and re-regulating the autonomic nervous system.

First, explain that the sympathetic nervous system responds to biological, psychological, and social stressors with a change in the amount of cerebral blood flow, which is what causes a person to feel dizzy.

Second, assess hydration, consistent eating (dips in blood sugar are physical stressors), and activity/exertion level. Often modifications in these areas is needed to improve overall health behaviors.

Finally, discuss how anxiety, and even normal/appropriate anticipatory anxiety, can further activate the sympathetic response, leading to dizziness even when stressors are not present in the moment (that is, thinking about something stressful can lead to the same sympathetic response as doing something stressful).

CBT strategies can then be used to modify unhelpful thinking patterns and reduce focus on the symptom leading to better functioning.

The term "unexplained" tends to be confusing for families because it sends the message that there may still be a medical/disease based reason for the symptoms and the right tests have not been run yet. If the patient has received a full workup, and their symptoms have been determined to be functional or somatic (that is, real, but not caused by an underlying disease or injury) the best course is for the treatment team to provide a positive diagnosis of the symptoms as functional somatic symptoms. Then, provide corresponding biopsychosocial education that sometimes the nervous system misfires and sends/receives signals between the brain and the body that may get started for an acute reason (for example, viral illness) but continue past the time when that is helpful (such as, the body is now healthy) and the symptoms then enter into a real but ultimately unhelpful cycle. A good analogy is to think about this as a fire alarm going off even after the fire has been put out — the alarm protected us from the danger but is now problematic because it is still ringing. For patients who are awaiting further testing, it can be helpful to introduce CBT as a way to cope with the symptoms (help with that ringing alarm) while they are waiting to see if there is still a fire.  However, due to the anxiety associated with diagnostic uncertainty, it is often most helpful for patients to have clarity around their symptoms prior to beginning a course of CBT.

After providing a comprehensive biopsychosocial explanation of how the autonomic nervous system responds to chronic stressors, this is a great opportunity to talk about how the brain starts to miss signals that could be helpful in slowing things down and preventing symptoms.

When a person with somatic symptoms experiences a biological, psychological, or social stressor, the brain over-responds with a boost of adrenaline via the fight or flight response to manage the stressor. Think about this like the brain “hitting the gas,” and all of a sudden the body is going 150 mph. The “faster” the body is going, the more it feels like it is on “high alert” and the more stressors are perceived and experienced. As a result, it can feel hard to sort through what is “causing” the symptom flare.

It helps to start thinking through what strategies can be used to slow the system down in general, before trying to determine specific strategies to be used when symptoms occur. For example, working with the patient on a consistent, well-paced daily routine with good sleep hygiene, regular meal times, hydration, and planned distracting/pleasant and relaxing activities is a great start. Think of these as speed bumps or stop signs to help slow the body down again and allow the brain to re-regulate its response. It is then a little easier to help the patient reconnect thoughts, feelings, and actions in order to work through what might be leading up to the triggering responses. At that point, behavioral interventions can also be quite helpful to manage symptoms in the moment and set goals to increase adaptive responses and the patient’s sense of control.