Linking teenager anxiety and GI disorders

Linking teenager anxiety and GI disorders | Image Credit: © New Africa - © New Africa - stock.adobe.com.

In this Contemporary Pediatrics® interview, Julia Anderson, MD, MSCI, pediatric gastroenterology, hepatology, nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt; and Sara Francis, PhD, Pediatric Psychology Division, licensed clinical psychologist, assistant professor of pediatrics, Vanderbilt University Medical Center, collaborated to discuss teenager anxiety and its relation to gastrointestinal (GI) issues.

Contemporary Pediatrics:

Can you explain this link between anxiety among teens and how it can cause GI issues?

Anderson and Francis:

Consider excessive, persistent anxiety and GI symptoms as 2 manifestations of 1 nervous system working overtime and showing signs of malfunction. Anxiety activates the “fight, flight, freeze” sympathetic nervous system, with adaptive sensations and responses including muscle tension, racing heart, and fast breathing. This same sympathetic nervous response turns down gut activity not critical to responding to a stressor, as that energy is needed elsewhere. When anxiety and stress persist, gut inhibition and dysregulation lead to GI issues like chronic nausea, vomiting, pain, or altered bowel movements.¹ For some youth, chronic functional abdominal pain results from this persistent, maladaptive pattern of signaling in the nervous system. Pain rehabilitation requires a biopsychosocial approach, which includes interventions to influence this complex interplay of biological, social, and psychological factors contributing to pain. Some of these factors include a child's physical health, family relationships and school environment, as well as psychological stressors like persistent anxiety.

Contemporary Pediatrics:

How can you explain this connection between anxiety and chronic GI pain to teens?

Anderson and Francis:

We offer education on nervous system’s functioning and its relationship to GI symptoms early in consulting with youth with chronic pain. Education about the complexity of pain is a critical, early intervention for youth and families who have struggled with debilitating symptoms that cannot be explained or treated from a purely biological perspective. For some teens and families, metaphor is a useful way to explain chronic GI pain. Your mind and body work like a stereo, and the volume of pain signals can be turned up or down. The volume is turned up with worry, stress, poor nutrition, dysregulated sleep, or excitement. The volume can be turned down with healthy sleep, diet and exercise, daily relaxation tools to regulate the nervous system, and in some cases with medication to target symptoms. A key component of treatment includes having a medical team validate a patient’s very real symptoms and developing an individualized treatment plan through a biopsychosocial lens to help with symptoms in the short and long term. ​

Contemporary Pediatrics:

Are GI disorders among youth increasing amid the mental health crisis?

Anderson and Francis:

There has been a sharp rise in diagnosed psychological disorders and significant mental health concerns since the mid-2000s in children and older adolescents,^2,3 which have continued to escalate since the COVID-19 pandemic. During the pandemic, the rates of anxiety increased, with 20% of youth reporting anxiety symptoms.⁴ Child- and caregiver-reported childhood anxiety continued to increase in post-pandemic, gradual reopening phases.⁵ Isolation and trauma-related stressors during the pandemic, combined with ongoing influences from social media culture, national violence, and school shooting all contribute to the rise in stress and anxiety among teens. With this rise in anxiety, we see more dysregulated sleep and eating patterns, impaired coping resources and skills, and, in turn, increasing somatic symptoms like chronic abdominal pain, nausea, and vomiting.

Contemporary Pediatrics:

How can health care professionals link functional GI disorders to anxiety when a patient is in for a visit?

Anderson and Francis:

When evaluating a patient with chronic abdominal pain or other GI symptoms, it is important to screen for anxiety and to query teens about feeling nervous or tense, changes in sleep patterns, feeling chronically weak or tired, and having difficulty controlling worry. “Red flag symptoms” such as weight loss, blood in stool, hematemesis, a sudden change in bowel habits, or recurrent joint pains or mouth sores should prompt evaluation for an organic etiology but the psychological and social factors that contribute to pain should still be considered. It is most useful to consider and to screen for functional GI disorders early in the diagnostic process as opposed to after exhaustive testing has failed to uncover “anything wrong.”​

Contemporary Pediatrics:

How are GI disorder patients with anxiety treated compared to those with just GI disorders?

Anderson and Francis:

Patients with comorbid anxiety are treated medically the same but those with clinically significant anxiety benefit from education on the complex, mind-body connection. One of the most important aspects of treating functional GI disorders is validating that the symptoms are real and not “all in their heads.” (i.e., only psychologically based). The emphasis on the multifactorial biopsychosocial model of pain is critical for patients with functional GI symptoms. Note, too, that this education is important for those with a known biological cause, as stress, fatigue, and poor healthy habits can exacerbate an organically based problem as well. Cognitive behavioral therapy, hypnotherapy, mindfulness-based therapies, and exposure-based therapy are evidence-based interventions that can help with functional gastrointestinal disorders (FGIDs) and those with comorbid anxiety.⁶ Medications can also be targeted to the patient’s predominant or most bothersome symptoms (i.e., pain, bloating, diarrhea, or constipation).

Contemporary Pediatrics:

Do these symptoms persist into adulthood?

Anderson and Francis:

There is evidence that depressive symptoms in childhood significantly predict FGIDs in adolescence and young adulthood. Longitudinal studies investigating irritable bowel symptoms starting in childhood and adolescence suggest that they will persist into adulthood in one-third to one-half of affected patients.⁷ This highlights the importance of assessing for depression and anxiety when evaluating a child with chronic abdominal pain and other persistent GI symptoms.

References:

1. Reed-Knight B, Maddux MH, Deacy AD, Lamparyk K, Stone AL, Mackner L. Brain–gut interactions and maintenance factors in pediatric gastroenterological disorders: Recommendations for clinical care. Clinical Practice in Pediatric Psychology. 2017;5(1):93-105. doi:10.1037/cpp0000166

2. Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005-2017. J Abnorm Psychol. 2019;128(3):185-199. doi:10.1037/abn0000410

3. Tkacz J, Brady BL. Increasing rate of diagnosed childhood mental illness in the United States: Incidence, prevalence and costs. Public Health Pract (Oxf). 2021;2:100204. Published 2021 Oct 15. doi:10.1016/j.puhip.2021.100204 

4. ZeytinogluS, Morales S, Lorenzo NE, et al. A Developmental Pathway From Early Behavioral Inhibition to Young Adults' Anxiety During the COVID-19 Pandemic. J Am Acad Child Adolesc Psychiatry. 2021;60(10):1300-1308. doi:10.1016/j.jaac.2021.01.021

5. Rappaport LM, Mactavish A, Mastronardi C, et al. Monthly correlates of longitudinal child mental health during the COVID-19 pandemic according to children and caregivers [published online ahead of print, 2022 Dec 9]. Eur Child Adolesc Psychiatry. 2022;1-12. doi:10.1007/s00787-022-02121-4

6. Person H, Keefer L. Brain-Gut Therapies for Pediatric Functional Gastrointestinal Disorders and Inflammatory Bowel Disease. Curr Gastroenterol Rep. 2019;21(4):12. Published 2019 Mar 12. doi:10.1007/s11894-019-0683-8 

7. Horst S, Shelby G, Anderson J, et al. Predicting persistence of functional abdominal pain from childhood into young adulthood. Clin Gastroenterol Hepatol. 2014;12(12):2026-2032. doi:10.1016/j.cgh.2014.03.034