Discussion

Revised Children’s Depression and Anxiety Scale was first designed in 2000 by Chorpita and colleagues to assess anxiety and depression symptoms in children. ^{Reference Chorpita, Yim, Moffitt, Umemoto and Francis5} It is a 47-question survey with answers 0 to 3: 0 = never, 1 = sometimes, 2 = often and 3 = always. Revised Children’’s Depression and Anxiety Scale was adapted to Turkish language and validation studies were done by Gormez et al. in 2017. ^{Reference Gormez, Kilincaslan and Orengul6} Revised Children’’s Depression and Anxiety Scale has a Cronbach’s alpha value of 0.86 for major depressive disorder and 0.75–0.85 for anxiety disorders subtypes.

Patients of all ages feel concerned when they experience any complaint possibly related to heart diseases. Rohani et al. investigated 250 adults before exercise stress test and found 42% had anxiety symptoms and 31% had depressive symptoms. ^{Reference Rohani, Akbari and Zarei7}

Many studies in the literature demonstrate that children rarely have cardiac condition-related chest pain. Evangelista et al. investigated 50 patients between ages 5 and 21 and found 76% of them had musculoskeletal pain, 12% exercise-induced asthma, 8% gastrointestinal problems and 4% psychogenic chest pain. ^{Reference Evangelista, Parsons and Renneburg8} Percentage of psychogenic chest pain among children seems to differ in similar studies. For instance, Pissarra et al. retrospectively investigated 798 children admitted to emergency departments with chest pain and found 21.6 % had psychogenic chest pain. Female gender, adolescent age, positive family history, previous stressful event, and normal physical examination were significantly related with psychogenic chest pain. ^{Reference Pissarra, Pereira, Amorim, Neto, Lourenço and Santos9} Similarly, in a recent study, 352 children with chest pain admitted to the paediatric emergency department were thoroughly investigated and 9.3 % were found to be psychogenic. Similar to our study group, most of their patients described their chest pain as sharp, like stabbing (59.9%) or as pressure (27.2%). ^{Reference Yildirimcakar, Omay and Açar10} Lipsitz et al. found psychogenic aetiologies in 56%, whereas Tunaoglu et al. found 75% in their studies. ^{Reference Lipsitz, Masia and Apfel11,Reference Tunaoglu, Olgunturk, Akcabay, Oguz, Gucuyener and Demirsoy12} A review by McDonnell showed psychogenic causes in 2–19% of children with chest pain. ^{Reference McDonnell, White and Grady13} Another study showed that 20.5 % of children with chest pain had panic disorders, and anxiety and depressive symptoms were common comorbidities. ^{Reference Milov and Kantor14} In a recent study, Aygun et al. reported psychogenic aetiologies in 28% of 782 children with chest pain. ^{Reference Aygun, Aygun, Uysal, Aygun, Dursun and Irdem1}

It is reasonable to think that the type of the study centre (emergency department or outpatient clinic) can affect percentage of psychogenic chest pain. It seems likely that higher numbers of psychogenic chest pain patients were seen initially at the emergency departments and these patients were referred preferentially to psychiatrists. In the literature, cardiac aetiologies were found in 3% of such patients in emergency departments and in 6–7% in paediatric cardiology outpatient clinics. ^{Reference Zavaras-Angelidou, Weinhouse and Nelson15-17}

It is easily observed that chest pain and psychogenic symptoms have a bidirectional relationship. Psychogenic symptoms can be somatised as chest pain, as chest pain can cause psychogenic symptoms like anxiety. Hiscock et al conducted a study in a third-level hospital emergency department to find out the reasons for families to bring their children to emergency department with anxiety and depressive symptoms. They reported most common reasons being hearing a medical opinion of trusted healthcare professionals, finding no alternative options, despair, ensuring the safety of their children, excluding a potential medical threat. ^{Reference Hiscock, Connolly and Dunlop17} Lipsitz et al. found higher anxiety symptoms in children with non-cardiac chest pain than in the asymptomatic control group. ^{Reference Lipsitz, Masia-Warner and Apfel2} In a study reporting considerably higher percentage of anxiety, Kenar et al compared 76 children with non-cardiac chest pain with 51 healthy volunteers and reported anxiety levels were significantly higher (79%) in the non-cardiac chest pain group. ^{Reference Kenar, Orun, Yoldas, Kayali, Bodur and Karademir18} We found 16% (n:8) of our patients had anxiety symptoms and 18% (n:9) had anxiety + depression symptoms before treadmill testing. These give us enough reasons to underline offering psychogenic evaluation for selected cases.

We also observed a higher frequency of elevated anxiety and anxiety + depression scores in females. Six of 8 patients with anxiety and seven of nine patients with anxiety + depression were girls. Psychogenic chest pain seems to be more common among girls and adolescents in current literature. ^{Reference Kenar, Orun, Yoldas, Kayali, Bodur and Karademir18}

One of our limitations was not evaluating parents and families for their children’s anxiety. The parents or caregivers are also worried when children report heart-related complaints. Akrivopoulou et al. found high scores of anxiety among families even when they are referred to cardiologists for innocent murmurs. ^{Reference Akrivopoulou, Gkentzi, Fouzas, Vervenioti, Dimitriou and Karatza19} They thought murmurs were indicative of a serious heart condition, 48% thought their children would be unable to participate in sports or make any physical activities. ^{Reference Akrivopoulou, Gkentzi, Fouzas, Vervenioti, Dimitriou and Karatza19} Children with chest pain are often restricted from physical activities by their families or teachers. ^{Reference Selbst, Ruddy, Clark, Henretig and Santulli20-Reference Kaden, Shenker and Gootman23} Even children themselves avoid forceful physical activities or change their behaviour accordingly. Lipsitz et al. demonstrated that children were restricted from climbing stairs, going to sleep, maintaining sleep, sports participation, and staying in school. ^{Reference Lipsitz, Gur, Albano and Sherman21} Kaden et al. showed 44% of children developed behavioural changes like carrying a heavy backpack, fast walking, sports activities in children experiencing chest pain. ^{Reference Kaden, Shenker and Gootman23} On the contrary, our study aims to show most of the time these behavioural changes are not necessary.

Most treadmill tests result normal in patients with non-specific chest pain. Anwar et al. reported 97.5% of exercise stress tests showed normal electrocardiographic monitorisation in children tested for various reasons, most commonly chest pain. ^{Reference Anwar and Kavey3}

It is noteworthy that researchers reported different outcomes for chest pain in children. Some think that healthy and informed patients nonetheless feel emotional stress and anxiety, complaining about chest pain even 1–2 years after their negative cardiac evaluation. ^{Reference Anwar and Kavey3} Another study showed that patients applied to different departments, even different hospitals, if they experienced unexplained chest pain. ^{Reference Pantell and Goodman24} We evaluated our patients with Revised Children’’s Depression and Anxiety Scale with 1–7 days intervals. Further studies may focus on periodic re-evaluations in larger patient populations.

In our study, children were able to observe their own effort capacity in a trusted environment, under supervision of healthcare professionals, feeling safe and comforted by reassurance. We also believe that exclusion of possible heart diseases may have helped significantly relieve the anxiety. To the best of our knowledge, this is the first study in the literature.