A recent review highlights the importance of anxiety and functional abdominal pain (FAP) (JPGN 2013; 56: 469-74).
“Preliminary evidence suggests that anxiety frequently co-occurs with FAP. This is not to suggest that FAP is a manifestation of a psychological disorder, but rather that anxiety and FAP may frequently co-occur because of potentially shared etiological factors (eg. heightened physiological arousal) or as a consequence of coping with recurrent pain.”
“Anxiety disorders are estimated to affect 42-85% of youth with FAP.”
Proposed guidelines for assessment and treatment of youth with FAP and anxiety:
Initial evaluation: build rapport between family and medical provider, assess for red flags, perform standard testing, anticipate and predict normal testing results, validate the pain experience is real, educate regarding pain sensation via brain-gut axis, administer anxiety screener (see below)
Management: reassure family that FAP is not a failure to identify an organic condition, avoid extensive testing, consider a low-dose antidepressant when appropriate
Psychosocial: if elevated levels of anxiety, refer for assessment by a psychologist, educate families about cognitive-behavioral treatment
With regard to screening, the authors propose the Screen for Child Anxiety and Related Disorders (SCARED) tool. From the University of Pittsburgh website,
- Target Population: Children ages 8-18 years
- Intended Users: Clinicians and psychiatrists
- Time to Administer: 10 minutes
- Completed By: Children and parents
- Modalities Available: Handwritten
- Scoring Information: Severity of symptoms for the past three months is rated using a 0 to 2-point rating scale with 0 meaning not true or hardly ever true, 1 meaning sometimes true, and 2 meaning true or often true.
Many other subspecialists joke about the need for a psychiatry degree to be an effective pediatric gastroenterologist; this review suggests that they are not far off the mark.
Take-home message: the review covers important aspects of this ubiquitous problem. Trying to get patients (and their parents) to address anxiety will likely improve outcomes of children with FAP.
Related blog links:
- -JPGN 2011; 53: 200. n=98. 79% of FAP responded to low dose tricyclics
- -Gastroenterol 2009; 137: 1261, 1207– Editorial. Amitriptyline helped in 66% vs 58% w placebo. n=90. dose 10mg <35kg, 20mg >35kg. 89% had failed Rx prior to study. ‘inability to use placebo.. in practice may justify amitriptyline Rx. Consider hypnotherapy/CBT first.’
- Distraction/ignoring important: Pain 2006; 122: 43-52. (Walker LS et al), J Pain 2006; 7: 319-26.
- -J Peds 2009; 154: 313 (editorial), 322. Prospective school study. n=237. Weekly prevalence of abd pain was 38%. 18% with persistence for >12 weeks. FAP persists into adulthood in 1/3 to 1/2 of cases (Clin Gastro Hepatol 2008; 6: 329-32).
- -Acta Paediatr 2007; 96: 697-701. Maternal anxiety is most consistent predictor of outcome.
as the parent of a child diagnosed with FAP in Jan this year, i think this reinforces the need for a child presenting with FAP to be assessed as a whole and for a wider team to be involved. if the pain (and psychological interventions around this) are not managed effectively then these trigger anxiety. what matters to child and parents in the longer-term, i think, is not so much the diagnosis, but what next, what comes after? my daughter was prescribed Gabapentin (Neurontin) last week after more than four months of near constant pain – in the end, the prescription came from a paediatric rheumatologist not a gastroenterologist. my daughter’s pain is now very greatly reduced – and i wonder why she was not prescribed this earlier. our family will continue with psychological support – that matters. psychology alone might have resolved the pain, in time. i don’t know. it seems to me that FAP is poorly understood and understanding is hampered to some extent by clichés.
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