Unexplained Chronic Pain and Psychiatric Disorders in Children

Children experiencing unexplained chronic pain also often have anxiety disorder or other psychiatric morbidity.

Research shows that psychiatric morbidity is common in children with unexplained chronic pain. A comprehensive work-up that includes structured interviews with the child and parent, as well as clinical observation and interview of the child by a pediatric psychiatrist, is important to creating a complete diagnostic picture and identifying children who are at risk for treatable psychiatric disorders.

Unexplained chronic pain (UCP) is quite common in children and adolescents and, according to the authors of “Psychiatric Disorders in Children and Adolescents Presenting with Unexplained Chronic Pain: What is the Prevalence and Clinical Relevancy?”, published in the January 2011 issue of European Child and Adolescent Psychiatry, there is “increasing evidence that psychiatric symptoms and psychiatric disorders are also involved” in this patient population. However, there is relatively little information about the prevalence of psychiatric morbidity in children with UCP and whether the inclusion of a psychiatrist in the diagnostic process produces added clinical benefit. This is a salient question because, as the authors note, although guidelines for UCP “advocate a combination of psychological, physical, and pharmacological treatment,” they focus mainly on pain control, not on managing comorbid psychiatric disorders. Because there is “strong evidence for psychological and pharmacological treatment of child psychiatric disorders,” if it can be established that UCP is indeed associated with psychiatric morbidity then “identification of children with UCP at risk of psychiatric disorders [will therefore be] required, because it justifies referral for psychiatric assessment and care.”

To assess the prevalence of clinically relevant psychiatric disorders and their predictors in children with UCP, Dutch researchers looked at data from 134 subjects in the Pain of Unknown origin in Children study, which enrolled children between the ages of 8 and 18 years who reported experiencing chronic pain for at least three months prior to first visiting the study clinic and who did not receive an explanatory diagnosis from the referring physician. Participants were assessed for the presence of possible psychiatric disorders using the Diagnostic Interview Schedule for Children (DISC) — a “highly structured respondent-based interview for children” -- and the Clinical Interview for Children and Adolescents (SCICA), administered by a child psychiatrist. For this study, the researchers used the parent version of the DISC. Subjects’ degree of psychiatric impairment was assessed using the Children’s Global Assessment Scale (CGAS); the children rated their pain using the Visual Analogue Scale of the Varni/Thompson Pediatric Pain Questionnaire (PPQ-VAS).

The study authors found that, based on the parental interview, 40% of the children had a psychiatric disorder, but only 21% had a psychiatric disorder that was “clinically relevant.” Anxiety disorder was identified in 18% of the children (including specific phobias, separation anxiety disorders, social phobias, and generalized anxiety disorders). Other disorders identified in this group included affective disorder (in 5% of the children) and disruptive disorder (5%). When looking at SCICA results, the authors found that 53% of the children had a psychiatric disorder, with 29% having a clinically relevant disorder. Nearly 15% of the children had a psychiatric diagnosis according to both DISC and SCICA; nearly 35% of the children had a clinically relevant psychiatric disorder assessed by one or both instruments.

Demographic factors such as age, sex, and socioeconomic status were not predictive of clinical psychiatric disorders. Analysis of other pain parameters (duration, location, etc) produced mixed results; however, headache as the primary location of pain “was a significant predictor of a clinical psychiatric diagnosis” in patients assessed by DISC and SCICA.

Based on these results, the authors concluded that “the high prevalence of clinically relevant psychiatric disorders in this referred sample with UCP has implications for diagnosis and treatment in daily clinical practice. When a child presents with UCP, it is essential to make a careful psychiatric assessment, including a professional child observation and interview, symptom severity, and impairment.”

The authors recommend that “When a child presents with UCP, it is essential to make a careful psychiatric assessment, including a professional child observation and interview, symptom severity, and impairment. If psychiatric disorders are present, evidence-based child psychiatric treatment should be offered.” Although there has been little research on the pain-management effects of depression treatment in children, studies in adults have shown that successful treatment for depression also has a beneficial effect on patients’ chronic pain. Therefore, because children with UCP “frequently experience limitations and impairments in their daily activities, which interfere with their development,” the authors recommend that “any physical, psychological, or psychiatric treatment able to reduce this interference should be incorporated in a tailored treatment plan.”