Psychopathology and Disability in Children With Unexplained Chest Pain Presenting to the Pediatric Emergency Department

Abstract

Objective: Chest pain is a common presentation in the pediatric emergency department (PED). In the majority of cases, no clear medical cause is found. Among adults with noncardiac chest pain, psychopathology including panic disorder is common. We assessed the likelihood and type of psychopathology as well as the health status of children and adolescents with unexplained chest pain who presented to the PED.Methods: We performed a semistructured diagnostic interview of children 8 to 17 years old who presented to an urban, tertiary-care PED with a primary complaint of chest pain for which no medical cause was found. We used Diagnostic Statistical Manual of Mental Disorders, Fourth Edition criteria to diagnose psychopathology. We also assessed pain severity, extent of other somatic complaints, quality of life, and functional disability using standard, validated instruments. Results:We enrolled 32 children with a mean age of 12.8 (SD, 2.9) years (range, 8Y17 years); 47% were female. Twenty-six (81%) were diagnosed with a Diagnostic Statistical Manual of Mental Disorders, Fourth Edition anxiety disorder; 9 (28%) had full-criteria panic disorder. Quality of life was compromised in multiple domains, and children reported a range of functional disabilities due to chest pain. Other somatic symptoms, including other pain complaints, were commonly reported in this sample.Conclusion: Unexplained chest pain in the PED is frequently associated with potentially treatable anxiety disorders. Emergency physicians should consider the possibility of anxiety disorders in patients with medically unexplained chest pain.C hest pain is a common complaint in the pediatric emergency department (PED). 1Y3 Annually, it accounts for roughly 400,000 emergency visits in the United States for individuals 18 years or younger. 4 Chest pain presents a significant clinical burden for the pediatric emergency room physician 5 and is one of the more common reasons for performing electrocardiograms in the PED. 6 It is also a frequent cause for seeking pediatric cardiologist consultation within the hospital setting 7 and is among the most common reasons for referral to the pediatric cardiologist. 8 Prior to adulthood, chest pain is only rarely an indication of cardiac disease. In studies of children with chest pain, prevalence of cardiac abnormalities ranges from 0% to 10%. 2,3,9Y11 Noncardiac medical diagnoses are common, including musculoskeletal conditions such as costochondritis, 12 pulmonary conditions such as asthma or pneumonia, 13,14 gastrointestinal illnesses, 15,16 or other identifiable causes such as cocaine use. 17 However, most cases have no clear medical explanation. 18 Despite the overall benign medical picture, pediatric chest pain often persists for years after the first visit to the PED or specialist. 19,20 Some children with chest pain make repeated visits for additional medical testing. 21 Many experience disability, including school absence and sleep abnormalities. 2,19,22 Our objective was to conduct a pilot study to determine the li...

Psychiatric Disorders in Youth with Medically Unexplained Chest Pain versus Innocent Heart Murmur

“…In two preliminary studies we identified high rates of psychiatric disorders in youth with unexplained chest pain (12,13). We undertook a case-control study comparing youth seen in outpatient cardiology consultation for medically unexplained chest pain to a control sample of youth with innocent heart murmur.…”

Noncardiac Chest Pain in Children and Adolescents: A Biopsychosocial Conceptualization

“…These findings also demonstrate that while some pediatric NCCP patients do meet criteria for panic disorder or another anxiety disorder, a number do not; this emphasizes that at least some NCCP patients suffer from a singular ailment that is distinct from undiagnosed panic or anxiety disorder. Still, the relatively small and homogenous samples utilized in these studies limits the generalizability of these findings and indicates the need for replication with larger, more diverse samples [13,15].…”

“…Unfortunately, details regarding the nature of the psychiatric interviews used in these three studies [27][28][29] are not reported. Structured diagnostic interviews demonstrated lower prevalence of depression, with 8-19% of patients meeting DSM-IV diagnostic criteria for a depressive disorder [13,15], although again the small sample sizes constitute a limitation. However, standardized self-report measures also suggest a lower rate of depression, with 11% of patients reporting elevated depressive symptoms, comparable to depressive symptoms reported by patients with benign heart murmurs [14].…”

“…Based on interviews using a structured protocol (the Anxiety Disorder Interview Schedule for DSM-IV: Child and Parent Versions ADIS-IV:C-P) that assesses anxiety, mood, somatoform and behavioral disorders [43], 59-81% of patients met DSM-IV diagnostic criteria for a current anxiety disorder, and 30-59% met criteria for two or more current anxiety disorders [13,15]. Among patients with anxiety disorders, approximately one-third to one-half meet criteria for panic disorder [13,15]. This is unsurprising, as the central feature of NCCP, chest pain, is also a physical symptom experienced by some individuals during panic attacks.…”

“…Although recent empirical research regarding psychosocial correlates of pediatric NCCP [12][13][14][15] has provided the invaluable beginnings of a psychological perspective on this complaint, these findings have yet to be integrated with extant medical research within a cohesive conceptual framework. We propose that pediatric NCCP is currently best conceptualized using a diathesis-stress model in which multiple elements independently or in combination confer a degree of risk for NCCP, which may then be triggered by various instigating factors.…”