Abdominal pain in childhood was associated with anxiety disorder

Functional abdominal pain in childhood was associated with anxiety disorder and depression in teens and young adults, even if the stomach pain went away, a longitudinal study showed.

Anxiety disorder was 4.9-times more likely at some point up to a mean age of 20, and 3.36-fold elevated (versus controls) even for those whose medically-unexplained abdominal pain resolved, Lynn S. Walker, PhD, of the Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, Tenn., and colleagues found.

Any depressive disorder in their early lifetime was 2.62-times more likely compared with controls who had never had functional abdominal pain, the researchers reported in the September issue of Pediatrics.

The findings underscore the importance of screening for anxiety and depression in this patient population, the group argued.

“The data are particularly compelling in that they reflect clinically significant disorders based on clinicians’ judgment that severity or impairment was moderate to high,” they noted.

Evaluating the pain in a biopsychosocial framework to catch psychiatric comorbidities early is important for chronic or recurrent abdominal pain, but also for other pain disorders in childhood, commented Lonnie Zeltzer, MD, director of the Pediatric Pain and Comfort Care Program at the University of California Los Angeles.

“This study provides further rationale for not just treating children with abdominal pain with medication aimed at pain, since the psychiatric comorbidities of social anxiety, separation anxiety, and depression may be causing more problems with the everyday lives of children than the pain itself,” she told MedPage Today.

That takes a team approach, partnering with behavioral health professionals early on, agreed Ritu Verma, MD, section chief of gastroenterology at The Children’s Hospital of Philadelphia.

“As gastroenterologists we already know there is a strong correlation between the brain and the gut, and it’s often unclear what comes first, the pain or the anxiety,” she said in an email.

In the study, most of the patients had an onset of anxiety disorders before their pediatric evaluation for functional abdominal pain. Depression typically developed later on.

Whichever comes first, though, the pain and psychiatric diagnoses may interact in a vicious cycle, Zeltzer noted.

“School absences traditionally thought to be a problem in children with chronic pain because of the pain, may in fact be related to social anxiety, which then increases the pain and pain-associated disability,” Zeltzer wrote in an email, pointing to the particularly high rate of social anxiety disorder.

The study included 332 consecutive pediatric functional abdominal pain patients seen at a single center, and 147 controls from a school-based health survey during the same period and in the same age range who never developed abdominal problems.

The follow-up interval for both groups ranged from 4 to 16 years, at a mean age of 20 years (range 12 to 32).

At follow-up, 41% of those with childhood functional abdominal pain met criteria for some kind of functional gastrointestinal disorder.

Current anxiety disorders were seen in 30% of the childhood functional abdominal pain group compared with 12% of the controls, which was a 3.57-fold difference in odds (P<0.001).

The difference in lifetime anxiety disorders was even more pronounced, at 51% versus 20%, respectively (P<0.001).

Lifetime depressive disorders were present in 40% of the childhood functional abdominal pain patients compared with 16% of the others (P<0.001), though prevalence of current depression didn’t differ.

The risk elevation was highest for those who still had some functional GI disorder, with odds ratios of 7.31 for lifetime anxiety disorder and 4.14 for lifetime depressive disorder.

But it was also significant for those who no longer had a functional GI problem, with ORs of 3.36 and 1.84 compared with controls (both P<0.05).

Limitations included the single “snapshots” of the cohorts in their childhood and teen or young adult years, the comprehensive subspecialty evaluation that might not generalize to children evaluated in primary care only, and the range of follow-up ages, though all analyses controlled for age.

Also, the study didn’t look at family history of anxiety or depression, family dynamics, or other external factors like bullying at school, Verma added.

The next step in research will be to determine whether early psychological intervention would impact long-term outcome and prevent these children from growing up with increased incidence of anxiety and depression, she suggested.

The study was supported by grants from the National Institute on Child Health and Development, the Vanderbilt Kennedy Center, Vanderbilt Digestive Disease Research Center, and the Vanderbilt CTSA from the National Center for Research Resources.

The researchers reported no conflicts of interest.

Primary source: Pediatrics

Source reference:
Shelby GD, et al “Functional abdominal pain in childhood and long-term vulnerability to anxiety disorders” Pediatrics 2013; DOI: 10.1542/peds.2012-2191.