FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Diagnosis: Somatic symptom disorder (SSD) – specifically with predominant pain (functional abdominal pain).
• DSM-5 criteria for SSD (all must be met):
1️⃣ One or more somatic symptoms that are distressing or disrupt daily life (abdominal pain, nausea).
2️⃣ Excessive thoughts, feelings, or behaviors related to the somatic symptoms, manifested by at least one of:
  • Disproportionate and persistent thoughts about the seriousness of symptoms.
  • Persistent high level of anxiety about health or symptoms.
  • Excessive time and energy devoted to symptoms or health concerns.
3️⃣ Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 months).
• This patient meets criteria: symptoms present 8 months, excessive worry about symptoms, school absenteeism (time/energy devoted to symptoms).
• Specify: With predominant pain (FAP).

✅ Candidate's answer:
• Rome IV criteria for FAP (must include all for ≥2 months):
1️⃣ Episodic or continuous abdominal pain.
2️⃣ No evidence of an inflammatory, anatomic, metabolic, or neoplastic process (normal workup).
3️⃣ Criteria not met for other functional GI disorders (IBS, functional dyspepsia, abdominal migraine).
• Relationship between FAP and SSD:
- FAP is a symptom-based diagnosis (focuses on the pain itself).
- SSD requires the psychologic component (excessive thoughts, anxiety, behaviors).
- Many children with FAP meet criteria for SSD because they have significant health-related anxiety and school avoidance.
- This patient has both pain AND excessive worry/school absenteeism → SSD.
- The distinction is important because SSD requires addressing the psychologic factors (CBT, anxiety treatment) in addition to pain management.

✅ Candidate's answer:
• Red flags (alarm symptoms) for organic abdominal pain:
- Systemic: Unexplained fever, weight loss, growth failure, night waking due to pain, fatigue.
- GI: Bilious or hematemesis, bloody stools (melena, hematochezia), nocturnal diarrhea, perianal disease (fissures, fistulas, tags), oral ulcers, dysphagia, persistent vomiting.
- Other: Arthritis, rash (erythema nodosum, pyoderma gangrenosum), uveitis, family history of IBD or celiac disease.
- Laboratory: Anemia, elevated ESR/CRP, low albumin, abnormal LFTs, positive celiac serology.
- Location: Pain that is localized to one quadrant (especially right lower quadrant – appendicitis, Crohn).
• This patient: No red flags – normal workup, no systemic symptoms, pain is periumbilical. Extensive workup already done.
• Do NOT order further tests – excessive testing reinforces illness behavior and increases anxiety.

✅ Candidate's answer:
• Predisposing factors:
- Perfectionistic personality (overachiever, worries about grades).
- Family history of anxiety (ask – likely present).
- Female sex (somatic symptoms more common in adolescent girls).
• Precipitating factors:
- Increased academic demands in middle school.
- Stress from tests, homework.
- Possible peer conflicts or social pressures (screen for bullying).
• Perpetuating factors:
- School avoidance → falling behind → increased anxiety → more pain (vicious cycle).
- Parental reinforcement (allowing child to stay home, excessive attention to symptoms).
- Multiple medical tests (reinforce belief that something is seriously wrong).
- Avoidance of normal activities (social withdrawal).
• Protective factors:
- Intact family, motivated to improve.
- No suicidal ideation or self-harm.
- Good premorbid functioning (prior good grades, friends).
- Normal physical health (no organic disease).
• Focus treatment on breaking perpetuating factors (school avoidance, parental accommodation).

✅ Candidate's answer:
• Role of the pediatrician:
1️⃣ Rule out organic disease – done (normal workup).
2️⃣ Stop unnecessary testing – do NOT order more tests. Excessive testing reinforces illness behavior, increases anxiety, and leads to iatrogenic harm.
3️⃣ Validate the pain – "The pain is real. It is not 'all in your head.' But it is not dangerous."
4️⃣ Explain brain-gut connection – stress and anxiety can cause real physical pain (brain-gut axis).
5️⃣ Reassure that no serious disease is present – red flags are absent.
6️⃣ Develop a school reintegration plan – gradual return, not complete avoidance.
7️⃣ Refer to mental health – for CBT.
8️⃣ Prescribe non-pharmacologic treatments – relaxation, biofeedback, hypnotherapy.
9️⃣ Treat comorbid anxiety/depression – consider SSRI if moderate-severe.
• Do NOT: Order more tests, prescribe opioids, or tell the patient "it's all in your head."

✅ Candidate's structured answer:
• “Thank you for asking that important question. The answer is NO – the pain is NOT ‘all in her head.’ The pain is real. Your daughter is not imagining it, and she is not faking it.”
• “What we have learned is that there is a direct connection between the brain and the gut – the brain-gut axis. When a person is stressed, anxious, or under pressure, the brain can send signals to the gut that cause real cramping, nausea, and pain.”
• “Think about when you are nervous before a test or an interview – you might get a stomach ache. That is the brain-gut connection. For your daughter, that response has become chronic because of ongoing stress.”
• “The good news is that because there is no dangerous disease, we can treat this by addressing the stress and teaching her relaxation techniques and coping skills. The pain will go away once she learns to manage her anxiety and return to her normal routine.”
• “We will NOT tell her ‘it’s all in your head.’ That would be dismissive and harmful. Instead, we will say: ‘Your brain is sending real pain signals, but we can teach your brain to calm down.’”

✅ Candidate's answer:
• First-line treatment: Cognitive-Behavioral Therapy (CBT) – the most evidence-based treatment for SSD and FAP.
• Key components of CBT for FAP:
1️⃣ Psychoeducation: Teach patient and family about the brain-gut axis, that pain is real but not dangerous.
2️⃣ Symptom monitoring: Track pain, triggers, associated emotions.
3️⃣ Relaxation techniques: Diaphragmatic breathing, progressive muscle relaxation, guided imagery.
4️⃣ Cognitive restructuring: Identify and challenge catastrophic thoughts ("The pain means something is terribly wrong" → "The pain is uncomfortable but not dangerous").
5️⃣ Behavioral activation: Gradually increase activity despite pain (opposite of avoidance).
6️⃣ School reintegration plan: Gradual return to school (e.g., 1 hour, then half-day, then full day).
7️⃣ Parent training: Reduce reinforcement of pain behavior (stop excessive attention, allow child to stay home).
8️⃣ Relapse prevention.
• CBT is typically delivered over 8-12 sessions by a psychologist. Refer this patient to a therapist trained in CBT.

✅ Candidate's answer:
• Principles: Gradual, planned, consistent. Do NOT allow complete avoidance – that reinforces the behavior.
• Step-by-step plan:
1️⃣ Collaborate with school: Meet with guidance counselor, teacher, school psychologist. Develop a 504 plan if needed (accommodations: breaks, late arrival, reduced workload temporarily).
2️⃣ Start with partial attendance: Example – attend school for 1 hour daily for 3 days; then 2 hours; then half-day; then full day.
3️⃣ Reward attendance: Positive reinforcement for going to school (not for being sick).
4️⃣ No reward for staying home: If child stays home, no screen time, no fun activities – only rest.
5️⃣ Involve the child: Let her set goals (e.g., "I will go to school for first 2 periods").
6️⃣ Address academic catch-up: Arrange for homework to be sent home, tutoring if needed.
7️⃣ Treat comorbid anxiety with CBT.
• Do NOT allow complete school withdrawal or home schooling – this worsens prognosis.
- This patient needs an immediate school reintegration plan.

✅ Candidate's answer:
• First-line treatment is CBT, not medication. However, medications may be used for comorbid conditions.
• For comorbid anxiety or depression (which this patient has – perfectionism, stress):
- SSRIs (fluoxetine, sertraline, escitalopram) – reduce anxiety, which may reduce pain severity. Start low, go slow. Monitor for side effects (nausea, activation, suicidal ideation – black box warning).
- This patient's anxiety is mild to moderate → CBT alone may suffice.
• For pain (off-label):
- Cyproheptadine (antihistamine/serotonin antagonist) – may reduce FAP and abdominal migraine. Dose: 0.25-0.5 mg/kg/day.
- Amitriptyline (low dose) – tricyclic antidepressant, 10-25 mg at bedtime – modulates visceral pain. Requires ECG (QT prolongation).
- Peppermint oil – may help IBS-type pain.
• Do NOT prescribe opioids or benzodiazepines – risk of dependence and worsening of functional disorder.
- This patient should try CBT first; medication reserved if CBT insufficient or anxiety severe.

✅ Candidate's answer:
• HEADSS interview (conducted separately from parent, with confidentiality limits stated):
- H – Home: "How do you get along with your parents? Any conflict, divorce, moving recently?"
- E – Education: "How are you doing in school? What are your grades? Do you feel pressure to perform? Have you been bullied?"
- A – Activities: "What do you do for fun? Do you have friends? Have you stopped activities because of pain?"
- D – Drugs: "Have you ever tried alcohol, cigarettes, or drugs?"
- S – Sexuality: "Are you in a relationship? Any concerns about your body, sexual activity?"
- S – Suicide/Depression: "Everyone feels sad or angry sometimes. How about you? Have you ever felt so sad you wished you were not alive?"
• This patient likely has academic pressure, possible perfectionism, and social withdrawal (due to missed school). Assess for bullying.
• Also assess for somatization in family – does the mother have chronic pain or anxiety?

✅ Candidate's answer:
• Broad-band (general) screening:
- Pediatric Symptom Checklist (PSC-17) – parent and youth versions; screens for internalizing (anxiety/depression), externalizing, and attention problems. Quick, free.
- Strengths and Difficulties Questionnaire (SDQ).
• Narrow-band (focus on specific symptoms):
- Screen for Child Anxiety Related Emotional Disorders (SCARED) – for anxiety (GAD, social anxiety, separation anxiety, school avoidance).
- Patient Health Questionnaire-9 (PHQ-9) – for depression.
- Generalized Anxiety Disorder-7 (GAD-7) – for older adolescents.
- PHQ-15 – for somatic symptom severity.
• For this patient: PSC-17 (quick internalizing screen) + SCARED (anxiety likely) + PHQ-9 (depression screen).
- If scores above clinical cutoffs, refer to mental health.

✅ Candidate's answer:
• Prognosis is generally good with early, appropriate treatment (CBT, school reintegration).
- 50-70% of children with FAP improve within 1-2 years with non-pharmacologic interventions.
• Good prognostic factors:
- Short duration of symptoms (<6-12 months).
- Absence of comorbid psychiatric disorder (this patient has mild anxiety – treatable).
- Supportive family willing to change reinforcement patterns.
- Successful school reintegration.
- Good premorbid functioning.
• Poor prognostic factors:
- Long-standing symptoms (>2-3 years).
- Severe school avoidance (complete withdrawal).
- Comorbid depression, eating disorder, or severe anxiety.
- Parental reinforcement (secondary gain, parental anxiety about organic disease).
- Continued medical testing ("doctor shopping").
- This patient has moderate prognosis (duration 8 months, school avoidance moderate, mild anxiety) – good chance of improvement with CBT.

✅ Candidate's structured answer:
• “I want to be clear: You are NOT causing this. However, some of the ways you respond to her pain may unintentionally be making it last longer.”
• “When your daughter has pain, if you give her a lot of attention, let her stay home from school, bring her special food, and keep her in bed – these are well-meaning but they reinforce the pain behavior. Her brain learns that pain = attention and avoidance.”
• “To break the cycle, we need to change how you respond:”
1️⃣ Stop giving excessive attention to pain complaints – acknowledge briefly ("I'm sorry you feel bad"), then redirect to normal activities.
2️⃣ Do NOT allow her to stay home from school for pain (if red flags are absent) – she must attend school. We will start with a gradual return plan.
3️⃣ Reward healthy behavior, not pain behavior – praise her for going to school, doing activities, even if she has pain.
4️⃣ Do not take her to more doctors or order more tests – that reinforces the belief that something is seriously wrong.
5️⃣ Model calmness and reassurance – if you are anxious, she will be more anxious.
• “We will work together on this. It will be hard at first, but she will get better.”

✅ Candidate's answer:
• Somatic symptom disorder (SSD):
- Symptoms are non-neurologic – pain, nausea, fatigue, shortness of breath, etc. This patient has abdominal pain and nausea – fits SSD.
- No objective neurologic findings.
- Excessive thoughts, anxiety, and behaviors related to symptoms.
• Conversion disorder (functional neurological symptom disorder):
- Symptoms are neurologic – weakness/paralysis, abnormal movements, seizures (psychogenic nonepileptic seizures), swallowing symptoms, speech symptoms, sensory loss, vision/hearing changes.
- Clinical findings show incompatibility with recognized neurologic disease (e.g., Hoover sign, splitting at midline).
- Patient is not consciously faking (different from factitious disorder).
• Overlap: Both are somatic symptom and related disorders; both have psychologic contributors.
- This patient has abdominal pain (non-neurologic) → SSD, not conversion disorder.
- If she had weakness or seizures, consider conversion disorder.
- Management for both includes CBT, but conversion disorder may also require physical therapy.