Consider anxiety in patients who have chest pain. (Rarely Correlates with Heart Problems).
"If you have chest pain as an adult, there is a reasonable suspicion that there might be something wrong with your heart," said Dr. Lipsitz, a clinical psychologist at Columbia-Presbyterian Medical Center, New York. But a pediatric cardiologist of his acquaintance has found only one or two children with genuine heart problems among the hundreds he has evaluated for chest pain.
Somatizing--expressing emotional distress in somatic symptoms--is the most common presentation of psychopathology in children, said Dr. Lipsitz, who described two small studies he and his colleagues recently conducted.
The first, a pilot diagnostic study, involved interviews with 22 children, aged 7-18 years (mean 12.5, 55% female), who were seen in a pediatric cardiology clinic for chest pain. Each child and his or her parent was interviewed using the Anxiety Disorders Interview Schedule (ADIS). Panic disorder was the most common anxiety disorder in these children, found in 8 of the 22 (36%).
"Kids would call it chest pain, but when you ask them to describe it, it was an array of four or more symptoms that come on tin waves] and recurred enough times to meet the criteria for panic disorder," Dr. Lipsitz said.
Other common DSM-IV diagnoses in this group included generalized anxiety disorder in five children, social phobia in three children, specific phobia in three children, and obsessive-compulsive disorder in two children. Overall, 12 of the children (55%) had a diagnosable anxiety disorder and 7 (32%) had two or more anxiety disorders. Anxiety disorders were more prevalent in girls and in older children.
A second study involved a mailed survey of 98 children who had been diagnosed in a pediatric cardiology clinic with noncardiac chest pain who were compared with 33 children seen in the same clinic for a benign murmur. They were surveyed 12-30 months after their clinic visit. The survey included the Multidimensional Anxiety Scale for Children (MASC), the Childhood Anxiety Sensitivity Index (CASI), and the Children's Depression Inventory (CDI).
Compared with the children with benign murmur, the children with chest pain scored significantly higher on the MASC and CASI but showed no difference on the CDI. The children with chest pain scored higher on the physical symptoms and harm and avoidance subscales of the MASC, and there was a trend toward a higher score on the anxiety disorders index subscale as well.
Even though they had been reassured a year or more earlier that their hearts were fine, 57% of them reported chest pain sometimes or frequently, 49% reported their hearts skipping beats, 63% of them reported trouble catching their breath, and 28% reported feelings of dizziness. All these measures were significantly more frequent in the chest pain group.
"I think this is a group that lends itself extremely well to a cognitive-behavioral intervention," Dr. Lipsitz said. "I think these kids may do much better over time than just being told by the cardiologist that everything is okay, and just being sent mystified back home."
Dr. Lipsitz suggested an intervention that would, among other things, involve an explanation to the child that anxiety causes people to focus on minor somatic symptoms, and that the more one pays attention to these symptoms the more bothersome they become.
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|Date:||Mar 1, 2003|
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