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Editorial
Canadian Journal of Psychiatry: New Editor and New Policies
Joel Paris, MD
(PDF)

Guest Editorial
Risk Assessment in Psychiatric Practice
Kenneth Hashman, MD, FRCPC, DABPN
(PDF)

In Review
The Canadian Contribution to Violence Risk Assessment: History and Implications for Current Psychiatric Practice
Hy Bloom, LLB, MD, Christopher Webster, PhD, Stephen Hucker, MB, Karen De Freitas, MD
(PDF)

The Clinical Use of Risk Assessment
Graham D Glancy, MB, ChB, FRCPsych, FRCPC, Gary Chaimowitz, MB, ChB, FRCPC
(PDF)

The State of Contemporary Risk Assessment Research
Michael A Norko, MD, Madelon V Baranoski, PhD
(PDF)

Review Paper
Community Treatment Orders: Profile of a Canadian Experience
Ann-Marie A O’Brien, MSW, RSW, Susan J Farrell, PhD, CPsych*
(PDF)

International Dosage Differences in Fluoxetine Clinical Trials
Scott Patten, MD, Andrea Cipriani, MD, Paolo Brambilla, MD3, Michela Nosè, MD, Corrado Barbui, MD
(PDF)

Original Research
Panic-Agoraphobic Spectrum and Light Sensitivity in a General Population Sample in Italy
Letizia Bossini, MD, Mirko Martinucci, MD, Katia Paolini, MD, Paolo Castrogiovanni, MD
(PDF)

Psychotic Disorders Clinic and First-Episode Psychosis: A Program Evaluation
Suzanne Archie, MD, FRCPC, Jane Hamilton Wilson, RN, Kevin Woodward, BSc, Heather Hobbs, RN, Shelley Osborne, RN, Jean McNiven, RN
(PDF)

Screening for Mild Cognitive Impairment: Comparing the SMMSE and the ABCS
D William Molloy, MB, MRCPI, FRCPC, Timothy IM Standish, David L Lewis, PhD
(PDF)

Attention-Deficit Hyperactivity Disorder With and Without Obsessive–Compulsive Behaviours: Clinical Characteristics, Cognitive Assessment, and Risk Factors
Paul Daniel Arnold, MD, FRCPC, Abel Ickowicz, MD, FRCPC, Shirley Chen, MD, MPH, Russell Schachar, MD, FRCPC
(PDF)

Brief Communication
Validation de la version française de l’inventaire de détresse péritraumatique
Louis Jehel, MD, PhD, Alain Brunet, PhD, Sabrina Paterniti, MD, PhD, Julien D Guelfi, MD, Pr
(PDF)

Book Reviews
(PDF)

The Confinement of the Insane: International Perspectives, 1800–1965
Review by
Laurence Jerome, MD

Suicide in Children and Adolescents
Review by
Paul S Links, MD, FRCPC

Letters to the Editor
(PDF)

A Novel Form of Treatment Resistance in Anorexia Nervosa

Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture

Effectiveness of Risperidone in Delirium

Family-Oriented Rehabilitation for Unexplained Chronic Pain

Hypokalemia from Risperidone and Quetiapine Overdose

A Renewed Interest in Day Treatment

Quetiapine Therapy for Corticosteroid-Induced Mania

Letters to the Editor

Family-Oriented Rehabilitation for Unexplained Chronic Pain

Dear Editor: We present a case report to illustrate our experience with a family-oriented rehabilitation program for children and adolescents suffering from unexplained chronic pain.

Case Report

A girl, aged 12 years, had a 6-month history of unexplained abdominal pain described as a “hurt feeling inside,” fatigue, decreased concentration, sleep difficulty, and school avoidance. She was described as an excellent student and a perfectionist in all her activities. Consultations from a pediatrician, gastroenterologist, neurologist, and allergist ruled out significant organic pathology to explain her symptoms. Her parents were angry that a medical cause was not found and denied the existence of psychosocial stressors. The child’s aunt had recently died from a tumour that presented with unexplained pain symptoms for months prior to diagnosis.

Psychometric testing revealed an anxious coping style and perfectionist traits. During the assessment, the family expressed their feelings of anger about their aunt’s death and began to confront their unresolved grief. The patient began taking fluvoxamine 100 mg every night. As a goal of rehabilitation, we emphasized enhanced functioning, specifically, improved sleep, increased activities, and school attendance. We encouraged the parents to support these goals. After 3 weeks, the patient’s sleep improved, and her fatigue and pain decreased. She went to overnight camp for 2 months, returned home, and attended school. Monthly family meetings continued for 6 months. Fluvoxamine was discontinued, and the patient continues to be well at 9 months.

Discussion

Pediatric unexplained chronic pain (UCP) presents a diagnostic and management challenge. Typically, families believe that UCP has solely an organic cause and frequently resist suggestions that psychosocial factors may be responsible for its development or perpetuation (1,2,6). Consequently, such patients develop a pattern of help-seeking behaviour involving multiple diagnostic investigations, repeated emergency department visits, hospital admissions, and prolonged hospital stays (3). Family physicians, pediatricians, and specialists in gastroenterology, rheumatology, endocrinology, and neurology are consulted frequently.

To address this problem, we have established a multidisciplinary, family-oriented, and rehabilitation-focused program to treat patients with UCP. We use a battery of psychosocial self-report scales to evaluate perfectionism, anxiety, and depressive symptoms (4,5,7). Treatment goals focus on enhanced patient functioning (with emphasis on sleep, school attendance, and social interaction), rather than on the symptoms. The family is taught coping strategies for enhanced functioning. Existing similar programs are also oriented to coping and function rather to the pain symptoms (1). A selective serotonin reuptake inhibitor is added to address anxious coping.

In a pilot study evaluating this program, we administered self-report scales to 15 patients (5 boys and 10 girls; mean age 12.4 years, SD 3.2) with a minimum of 3 months of UCP. The referring physician excluded significant organic pathology. Overall, we found that anxious coping styles and difficulty with separation were common among the referred population. Levels of perfectionism fell between those in a healthy control group (low) and those in a group with anorexia (high). Elevations occurred in the domains of feeling unsatisfied after completing projects, high personal standards, and the need for order. These results were psychoeducational in that they helped parents and patients focus on the rehabilitation goals and enhanced their confidence in a program that targets function, rather than pain.

References

1. Bursch B, Wolco G, Zeltzer L. Clinical assessment and management of chronic pain and pain associated disability syndrome. Developmental and Behavioural Pediatrics 1998;19(1):45–53.

2. Campo JV, Fritsch SL. Somatization in children and adolescents. J Am Acad Child Adolesc Psychiatry 1994;33:1223–35.

3. Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Burns BJ, Brent D. Psychopathology in paediatric primary care: the new hidden morbidity. Paediatrics 1995;82:415–24.

4. Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cognit Ther Res 1990;14:449–68.

5. Kovacs M. The Children’s Depression Inventory. Toronto: Multi-Health Systems; 1983.

6. Livingston R, Taylor JL, Crawford SL. A study of somatic complaints and psychiatric diagnosis in children. J Am Acad Child Adolesc Psychiatry 1988;27:185–7.

7. March J. Multidimensional Anxiety Scale for Children. Toronto: Multi-Health Systems; 1997.

Gillian Kirsh, MA
Rose Geist, BSc, MD, FRCPC
Toronto, Ontario