Commentary on somatoform illness and patient characteristics.

Children with somatoform illness present a real diagnostic and management puzzle for the pediatric hospitalist. These children are a source of diagnostic confusion, often leading to unnecessary hospitalization, extensive testing, and frustration on the part of caretakers and providers. The psychiatric underpinnings of their clinical presentation are frequently only discovered through a process of elimination, leading to a diagnosis of exclusion for these children presenting with somatoform disorders. In this issue of Hospital Pediatrics, Bujoreanu and colleagues1 present their experience with this patient population in a large children’s hospital. This work, in association with a previous discussion on this topic in this journal,2 offers a way through this diagnostic challenge by identifying unifying characteristics that allow the hospitalists to “rule in” the psychiatric diagnosis early in presentation. This allows for the early intervention with the psychiatric consulting service, more informative dialogue with the parent and patient, and more goal-directed therapy. Importantly, because this condition copresents with other psychiatric diagnoses (anxiety and mood disorders commonly), psychiatric consultation may uncover these illnesses and allow for appropriate psychiatric based therapeutic interventions. Delayed or missing diagnosis of common psychiatric illness, frequent in the pediatric age group,3 suggests a reluctance or inability to make these diagnoses in this age group. Through a ruling-in process as suggested by the authors and by recognizing the unifying demographic, psychological, and medical characteristics of these children, we may better provide for them. By contrast, one typically adopts a “ruling-out” process when working through an organic illness diagnosis. We think of the most life-threatening medical complication in the differential, rule that out, and work sequentially in this way to arrive at a correct diagnosis. These contrasting approaches are not mutually exclusive and may be complementary. By adopting a ruling-in approach with psychiatric illness, we can offer earlier identifi cation of the correct diagnosis and offer earlier therapeutic intervention.