... Fear Itself

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.

A few months ago I was having lunch with a pediatrician who has more than 30 years of practice behind him. In addition to swapping war stories from the trenches and bragging about our grandchildren, we shared our long-range views of where pediatrics has been and where it is going.

One of the things we agreed on was that anxiety has been one of the primary emotions, if not the primary emotion, driving the problems we have seen in the office. It is tempting to place depression at the top of the list, particularly if you see a lot of teenagers in your practice. And of course one could argue that there is abundant evidence of the unfortunate effects that parental depression can have on the health of children. However, what makes anxiety stand out is that patients have a frustrating ability of burying it beneath a complex array of complaints. My friend and I may have been more correct to agree that anxiety is the most underappreciated emotion on the diagnostic menu.

For example, consider the child who is missing school frequently because of abdominal pain. She is on her expected growth curve and has unremarkable bowel movements. Would the experienced pediatrician send that patient to the gastroenterologist, or begin asking how things are going at school? Has a parent been sick or been away on business trips?

And what about the 6-year-old who suddenly begins making frequent trips to the bathroom to urinate, but sleeps through the night dry? I guess most of us would obtain a urine sample that we know is going to be normal. Old habits die hard. But the rest of the visit should be spent exploring whether he or a classmate has had a urine accident recently. Even a minor slip can trigger a fear that, "if I don’t keep my bladder empty, it’s going to happen to me."

And of course there are the legions of constipated stool retainers. To my way of thinking, most of these children have an anxiety problem. Rarely is there an obvious history of a painful bowel movement. But we have all known children who have passed many painful stools who don’t become so fearful that they decide not going to the bathroom is the better option. However, there is that group of children cursed with such a deeply ingrained anxiety about the pain that it will take a year or more of laxative-aided bowel movements to eradicate it. It is interesting that the solution is not SSRIs or extended counseling. I have seen both fail. There is a message there that I haven’t quite figured out yet.

Separation anxiety seems to be a normal part of the tool kit that babies are born with. The problem is that many parents have lost the tools in their kits to deal with it. The result can be years of lost sleep for entire families. Even for the parents who have mastered the challenge of saying good night or good-bye, a serious parental illness or longer-than-usual separation can reignite the child’s anxiety.

I have seen children who have refused to play outside because they have become afraid of clouds or butterflies. And there are those patients who have begun to refuse solids because of a minor choking episode. I’m sure you could add to the list and have your own tricks for managing them.

But no discussion of the power of anxiety would be complete without a mention of how our behavior as physicians is molded by fear. We can thank lawyers and, to some extent, ourselves for not coming to grips with that reality. Knowledge can be a potent anxiolytic. But we need a coordinated health delivery plan that can give us some protection or defensive medicine is going to keep costs spiraling upward. That is something to really fear.