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Undetected Pain Common in Teens With Eating Disorders

February 3, 2017
Although eating disorders and chronic pain may occur with comparable severity, eating disorders tend to go undetected for twice as long in adolescents who are also experiencing chronic pain, perhaps compromising effective treatment.

With Leslie A. Sim, PhD, LP and commentary by Alix Timko, PhD

Adolescents who present with chronic pain may also have an eating disorder that is likely to go undetected for much longer periods than when an eating disorder is the only diagnosis,1 according to new study findings.

In teens with both conditions, the eating disorder went undetected for twice as long as when pain was the primary complaint as compared those who sought medical help for an eating disorder, said study leader Leslie Sim, PhD, LP, associate professor of psychology and a pain psychologist in the Pediatric Pain Rehabilitation Center at the Mayo Clinic in Rochester, Minnesota. "Chronic pain appears to be obscuring the eating disorder, so these kids aren't being readily identified," Dr. Sim told Practical Pain Management.

Dr. Sim became interested in conducting the study after noticing that nearly 20% of youth referred to an eating disorders program arrived with a prior diagnosis of chronic pain. The study is published in the Journal of Pediatric Health Care.

Comparing Teens with 1 or Both Conditions    

Dr. Sim and her colleagues used a retrospective chart review, finding 34 teens with chronic pain and a concurrent eating disorder. They compared them with 34 teens matched for age, gender, and predominant eating disorder symptoms, but no complaints of chronic pain. The patients were followed for 6 years, from 2007 to 2013.

Undetected pain may be common in adolescents who also have an eating disorder.

Adolescents who presented with both conditions were commonly diagnosed with anorexia nervosa (AN), with about 62% receiving that diagnosis; the mean age of the teens was 16.2 years and nearly 86% were female. In the eating disorder only group, nearly 67% were diagnosed with AN, and their mean age was 15.9.

Adolescents who presented with a diagnosis of pain were referred from a variety of specialties, including pain rehabilitation programs, gastroenterology, multispecialty clinics, neurology, endocrinology, and primary care; and least often, psychiatry.

Most commonly, the site of pain was abdominal, with nearly 41% citing that area as the origin of their symptoms. Other sources of pain included postural orthostatic tachycardia syndrome/autonomic dysfunction cited by nearly 30%, headache for nearly 18%.1 The remaining 11% cited various other sources of pain.

Pain or Eating Disorder, Which Came First?

The pain was diagnosed before eating disorder symptoms in 41% of the teens that participated in the study, but in 35%, the eating disorder symptoms were identified first. The researchers could not determine temporal relationships in nearly 24%.

Unraveling which came first can be complicated, Dr. Sim told Practical Pain Management. Often, she has learned that making a diagnosis is not straightforward. For some teens, ''it started out that they were not eating because they wanted to control their pain.'' Others had an eating disorder that was masked as pain. Rather than say they were struggling with issues related to food/body image, they might say to their parents or someone else that "I can't eat, my stomach hurts.''

So their parents would typically send them to the pediatrician, Dr. Sim said, and the PCP would understandably focus on the pain, trying to alleviate it. Often, after much expense for a lengthy workup, the source was not found.

Many symptoms of both chronic pain and eating disorders are similar, which complicates the process of making a diagnosis, according to Dr. Sim. Among the common complaints were dizziness, weakness, fatigue, weight fluctuations, chest pain, heart palpitations, appetite changes, memory loss, and difficulty concentrating.

The time to diagnosis was 20.61 months in those with eating disorders and chronic pain, compared to 9.64 months in those without chronic pain.1 The mean difference was 10.97 months (95% CI, 5.07-16.87), p .001.)

Dueling Diagnoses: a Clinical Perspective

The new research will hopefully raise awareness among primary care physicians and pain specialists that the two conditions may coexist, said Alix Timko, PhD, assistant professor of psychology and psychiatry at the Perelman School of Medicine, University of Pennsylvania, and a clinical psychologist in the Eating Disorder Assessment and Treatment Program, Children's Hospital of Philadelphia. She reviewed the new study for Practical Pain Management.

"I'm not sure how many chronic pain specialists would be aware of the high degree of overlap," she said. "What's really significant about this study is that they found it took so much longer to diagnose the chronic pain patient with an eating disorder, “said Dr. Timko. “When it comes to eating disorders, we know that early identification and treatment is really key.''

The nearly 2-year lag based on this study for identifying eating disorders in the chronic pain patients1 is also troubling, Dr. Timko said, since adolescence is a time of critical brain development so a lack of nutrition can adversely affect it.

Incorporating Eating Disorder Assessment into Pain Evaluation

Both PCPs and pain specialists should be aware of the 2 conditions often coexisting, Dr. Timko said. "Eating disorders don't always present in the classic sense," she added. For example, not all teens with an eating disorder express body dissatisfaction.

Physicians should ask about teen behaviors, Dr. Timko says. "It is worth the providers' time to probe a little deeper, to get information from the parent [if necessary]. Ask them: does the teen avoid certain foods when the family eats dinner? When in doubt, she said, ''reach out to a colleague in eating disorders" for an opinion or referral.

Dr. Sim added, "don’t take 'I can't eat because I am in pain' at face value." And if an adolescent has lost unexplained body weight, she said, an eating disorder should be suspected. She recommended obtaining separate teen and parent reports when evaluating for a possible eating disorder. She recommended utilizing a few helpful resources: the Eating Disorders Examination Questionnaire and the Eating Disorder Test-26 as reliable measures of eating disorders and disordered eating, respectively.

No financial conflict of interest disclosed by Drs. Sim and Timko.

Last updated on: February 8, 2017
Continue Reading:
Managing Headaches in Children and Adolescents

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