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Letters to the Editor Indian Pediatrics 2000;37: 1400-1402 |
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Issues Related to the Psychological Aspects of Recurrent Abdominal Pain |
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Firstly, the authors mention that "the patients were assessed by a psychiatrist for psychological problem" but have not alluded to either the methods (clinical, psychometric, psychological, etc.) adopted or to the diag-nostic system so applied. Any condition where psychological factors are not readily evident require detailed assessment using the methods stated above; results thereby obtain-ed being then viewed and interpreted in a comprehensive manner to ascertain presence of psychological/psychiatric morbidity. As clinicians it is important to know as to what is their utility in the diagnostic work up; alluded to by the authors for endoscopy and brush cytology. Secondly, Table I details the psy-chological disorders. However, attention seeking behavior (ASB) is not a psychiatric diagnosis {see ICD-10(2)}; instead is a term for a psychological problem. Psychological problems (e.g., ASB) per se cannot be equated with psychiatric disorders (e.g., depression, anxiety disorders) as they can be part of the disorder which the child is suffering from. Herein, lies the importance of the diagnostic system applied for evaluation. Thirdly, 4 children had psychological causes and 8 children had organic plus psychological causes for RAP. Providing an etiological label to a disorder depends upon the correlation of illness onset with the etiological factor, con-firmatory laboratory evidence, and response to specific treatment. These yardsticks have been applied for labeling an organic cause for RAP, but not for psychological causes. It is well known that physical illnesses can lead to psychological problems/disorders. The psy-chological causes in these 12 children could have been a reaction to the primary physical symptom/illness, i.e., RAP. Hence, the etio-logical label so given is not justified. Fourthly, the 12 children with psychological problems responded to treatment. The sub-group with combined organic plus psycho-logical causes responded to which treatment modality (somatic, psychological or both) is not clear. Also, psychotherapy yielded excellent results–an interesting observation as disorders like depression show better response to pharmacotherapy(3), and anxiety disorders do not uniformly respond to psy-chotherapy. It would have been more helpful if the mode of treatment for children with psychological problems had been detailed. These observations need clarification as RAP is a condition requiring active liaison between psychiatry and pediatrics–a statement endorsed to by the authors themselves. This should help in the better understanding and management of this distressing illness. Lastly, Table II shows n = 26 whereas the sum total of cases listed underneath is 28 (107.6%)–a discrepancy! Nitin Gupta,
Since the article was published as a ‘brief report’ we didn’t have scope to elaborate on psychological aspects of our cases with recurrent abdominal pain. All the patients were clinically assessed by a psychiatrist using the DSMIV and ICD 10 criteria. Secondly, we quite agree with the obser-vation of the reader that attention seeking behavior (ASB) is not a psychiatric diagnosis. However, we would like to clarify that ASB was used as a broad term in psychological assessment of the patients and was not supposed to reflect a specific psychological diagnosis. We agree that before labeling an etiological diagnosis to a disorder, response to specific treatment must be seen and this has been done in the study. those with organic causes responded to specific drug therapy. Those with psychological problems leading to RAP received psychotherapy. Dr. Gupta is right that psychological problem can result from physical illness but that does not mean that psychological problem should not be taken care of. In fact this is the message of this article. It is well known that psychological problem can co-exist with organic cause of RAP and both have to be taken care of simultaneously to achieve satisfactory response to treatment. Also, it is unethical to deprive a child of either a drug or psycho-therapy. Children in organic plus psychogenic group received both drug therapy for organic etiology as well as psychotherapy for the psychological problem. We had three patients with depression and one with anxiety disorder who responded well to psychotherapy and did not require any pharmacotherapy. And lastly, there is no discrepancy in Table II. As two patients were common in giardiasis and chronic gastritis group, the total number of cases remains 26 though the total of ‘diagnosis’ is 28. This information has been clearly indicated in the Table as a footnote. Bharat Balani, |
