Dismissing chronic Lyme disease for somatic symptom disorder diagnosis

The authors of this case series suggest that children with chronic Lyme disease symptoms be re-evaluated and diagnosed with somatic symptom disorder (SSD). Their article “Somatic symptom disorder should be suspected in children with alleged chronic Lyme disease” appears in the European Journal of Pediatrics. [1]

Peri and colleagues reviewed the medical records of children admitted to a hospital in Italy between January 2016 and December 2018. They identified 26 children who had a diagnosis of Lyme disease. Seven fit the criteria for chronic Lyme disease. But the authors disputed these findings, suspecting instead that the patients suffered from a somatic disorder.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-V), somatic symptom disorder is defined as:

“the presence of nonspecific discomforting somatic symptoms (mostly head, abdominal, back, and muscle pains) and excessive thoughts on a possible disease, that seriously undermine children’s daily life causing in severe cases school absenteeism, loss of interests and activities, isolation from peer, abandonment of sports activities, for more than 6 months. The attention focused on somatic symptoms, the repeated request for help, and the avoidance of physical activity strongly support the diagnosis of SSD.”

All 7 children lived in an endemic area for Lyme disease. Two children had an IgM positive Western blot test, but none had a positive IgG test. Other diagnostic tests were negative.

All of the children were ill despite multiple courses of antibiotics. For 5 of the children, symptoms lasted longer than 6 months and “strongly impaired their school attendance,” writes Peri, a child neuropsychiatrist.

Their symptoms included headaches, reports of low-grade fever, arthralgias without signs of active inflammation and vague asthenia [abnormal physical weakness or lack of energy] not linked to physical efforts.

“One patient reported difficulty in walking so as to arrive at the use of a wheelchair and one visual disturbance,” writes Peri.

Four of the children had specific psychosocial risk factors, the authors explain, including “high school and family demanding with perfectionism features, the sudden death of a parent, a history of bullying, and gender dysphoria.” One child dropped out of school.

When re-evaluated by a pediatrician and a child neuropsychiatrist, the diagnosis for 6 of the 7 children was changed from chronic Lyme disease to a psychopathological disorder, mainly somatic symptom disorder.

Peri and colleagues ruled out Lyme disease because of “nonspecific symptoms” and the absence of a positive IgG Western blot test. The two positive IgM tests were assumed to be false positives.

The authors did not report whether the children who were re-diagnosed with somatic symptom disorder improved with treatment.

The remaining 19 children admitted for Lyme disease apparently did not suffer from somatic symptom disorder.

Editor’s note: The authors conclude that “like adults, children and adolescents labeled as affected by [chronic Lyme disease] may have a psychopathological disorder.” Unfortunately, too many patients with persistent symptoms of Lyme disease are dismissed and labeled as having aches and pains caused not by an infectious pathogen but by a psychiatric condition.