“Julie,” a previously physically healthy 12-year-old female, presented with 6 months of abdominal pain, weight loss, and emesis that began shortly after her parents divorced. As a result, she missed several weeks of schooling.
Work-up included a complete blood count, comprehensive metabolic profile, thyroid studies, C-reactive protein test, erythrocyte sedimentation rate, abdominal x-ray, abdominal ultrasound, upper and lower endoscopy, and stool culture, all of which were unremarkable. Eliminating gluten from her diet was not helpful. The patient had no previous physical health concerns, including no previous gastrointestinal pathology. There was no history of substance use, sexual activity, psychological trauma, or abuse.
Julie was admitted for her fourth medical admission within 4 months. Child and adolescent psychiatry was consulted for evaluation of anxiety. Julie and her parents were skeptical about any psychological factors influencing her presentation and were hesitant to agree to psychiatric consultation. The parents were advocating for the use of opioids for her pain and an expanded work-up.
The patient received concurrent evaluation by the pediatric hospitalist service, gastroenterology, psychology, and psychiatry. No further diagnostic testing was pursued. The team found Julie had comorbid learning difficulties, nonspecific anxiety, maladaptive coping, and increased familial expressed emotion contributing to her presentation in the context of the recent divorce. A multidisciplinary meeting was held with Julie and her parents to discuss the diagnosis of somatic symptom disorder (DSM-5 300.82). The family was presented with a conceptual framework for symptom development by the multidisciplinary care team, in addition to biopsychosocial contributors to her presentation and a future management plan.
Julie was referred for outpatient cognitive behavioral therapy and prescribed mirtazapine 7.5 mg at bedtime for anxiety and sleep difficulties. Her symptoms improved by discharge, and she was minimally symptomatic upon follow-up with her primary care provider