Abdominal pain: Gut feeling at the paediatrics clinic

17. December 2013
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Functional gastro-intestinal disorders often occur together with depression or anxiety disorders – even with children. Without timely interventive treatment psychosomatic diseases can work their way into adulthood. For this reason American paediatricians urge that it be looked at more closely.

Eight year-old Anne once again has abdominal pain, the third time this month. Her paediatrician cannot find any physiological factors – there is no evidence of appendicitis, gastritis nor of other illnesses. For him, it is now time to seek advice from colleagues: not infrequently, functional abdominal pain (FAP) can be explained by psychological or social causes.

School plus family equals abdominal pain

According to WHO estimates, one in five pupils in Germany knows the problem, either due to increasing pressure to perform, fear of failure or bullying in the classroom. Passive coping strategies, such as wishful thinking, avoidance or denial, are associated with stronger abdominal pain, anxiety and depression. In contrast, active coping strategies with a problem-solving approach allow the symptoms to subside quickly. Parents who respond over-protectively or extremely critically to abdominal pain complaints make matters significantly worse. On top of that mothers of affected children have anxiety or depression more often than is the population average. Well-intentioned suggestions directed to parents that their children will “outgrow” their mood disorders sooner or later by themselves are rather counterproductive. Already at first suspicion the only remaining option is to look at things more closely.

Rome helps out

In order to characterise FAP, doctors developed the Rome III Consensus Criteria. The essential point: that children or young people are found to suffer during any quarter-year period at least three times from FAP symptoms. These include dyspepsia, abdominal migraine and irritable bowel syndrome. Among younger patients, nausea, vomiting, diarrhoea, fatigue often occur, as well as headaches. Between 25 to 45 percent of all those affected, according to the study, have these discomforts five years or longer. Besides the actual symptoms themselves, performance deficits and social limitations make these school children’s lives even more difficult. They are rarely active in sports, hardly take part in extracurricular activities and in the long term have lower social competence. Yet that is only one aspect.

Anxiety and depression

Lynn Walker from the Vanderbilt University School of Medicine, Nashville, Tennessee, has now examined psychological comorbidities among 332 students from eight to 17 years. All of the children and adolescents suffered for at least three weeks from abdominal pain without physiological underlying conditions. The control group involved consisted of 147 symptom-free age-matched subjects. At the beginning gastrointestinal and psychiatric examinations were done, which were repeated as soon as the study participants had reached twenty years of age. At the follow up about 30 percent reported anxiety disorders, in the control group the figure was only twelve percent. The calculated lifetime risk was 51 percent (control group: 20 percent). In addition the lifetime risk for depression was significantly increased (40 percent versus 16 percent). Functional gastrointestinal problems were also experienced significantly more often. Given these figures, Lynn Walker strongly advises all paediatricians that abdominal pain occurring in the absence of an underlying disease be taken seriously. The complaints are considered indicators that patients are particularly vulnerable to depression and anxiety disorders and may have to fight against them even in young adulthood.

Adults in the test lab

In later years as well, the relationship between FAP and anxiety or depression remains conspicuous, reports Susanna A. Walter, Linköping. She randomly chose 272 subjects aged 27-71 years without having any other criteria. Gastro-enterological and laboratory investigations then followed so as to exclude physiological illnesses. The participants had to fill out a “health diary” and the modular Rome II questionnaire. Psychosomatic health disorders were recorded by Walter using the Hospital Anxiety and Depression Scale, and using the Short Form-36 information on health-related quality of life was obtained. Here too, the well-known picture formed: anxiety and depression scores were significantly higher among the participants with abdominal pains than for peers without the symptoms. Walter also found evidence that the quality of life is significantly restricted by FAP.

His soul, her soul

In this context, Michel Bouchoucha of Paris specifically investigated gender aspects. The researcher registered FAP symptoms among 385 patients by using the Rome III consensus criteria. Using an analogue scale, study participants were also able to specify symptoms such as abdominal pain, constipation or diarrhoea. Bouchoucha recorded mental health disorders via the Beck Depression Inventory or the State-Trait Anxiety Inventory. As Susanna A. Walter already previously did, her French peer found correlations between gastrointestinal problems, especially abdominal pain, and mental disorders. One important difference: In men there is a tendency toward anxiety disorders, while women are more likely to struggle with depression.

Multimodal approaches

What does all this mean in practice? For the assessment and treatment of FAP, Natoshia R. Cunningham, Cincinnati, has presented recommendations for action: first, those affected should be examined gastroenterologically – behind a supposed FAP there can still hide serious diseases. At the same time Cunningham warns patients without alarm symptoms against over-diagnosis. Rather, his advice goes, anxiety, depression and pain is to be captured statistically using appropriate scoring systems. With regard to treatment itself multidisciplinary approaches come into the picture, for example training given to children and parents. In the context of cognitive behavioural therapies children learn to understand their fears in an age-appropriate way and develop appropriate mitigation strategies together with therapists. With exposure therapy the core idea is that potentially frightening situations in everyday life be replayed. Cunningham considers low-dose antidepressants to also be suitable – more as a last resort, should worse come to worse.

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“first, those affected should be examined gastroenterologically – behind a supposed FAP there can still hide serious diseases” –
it is most important.

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