The role of psychological factors in pediatric functional abdominal pain disorders (FAPD)
Functional abdominal pain disorders (FAPDs) are a set of common childhood disorders that includes dyspepsia, irritable bowel syndrome and non-specific abdominal pain.
Psychiatric illnesses with FAPD
About 20%‐50% of children with FAPD suffer from anxiety or depression that is clinically significant. FAPD patients may later also develop anxiety and depression in adulthood. The symptoms of anxiety and depression are associated with increased severity of abdominal pain. Patients with anxiety or depression primarily could also develop abdominal symptoms secondarily. It could be argued that anxiety and depression are consequences of living with a painful and unpredictable disorder. But, studies in children have showed that both scenarios, long standing pain leading to psychiatric problems and primary psychiatric problems leading to pain are possible. Irrespective of which came first it is necessary to address both.
Children with FAPD also report other symptoms like headache, backache, bodyache etc. This is called as somatisation. This is seen more with girls. It is traditionally understood as repressed emotions being expressed through physical symptoms, but the exact cause is not known.
Stress in FAPD
Stress also plays an important role in FAPD. Life stressors could include school related stressors (eg, separation from a best friend, examination stress, bullying), family‐related stressors (eg, loss of a parents’ job, parents seperation) and health‐related stressors (eg, hospitalization, worry about pain). In certain situations, physical abuse could be the stressor.
Coping refers to the manner in which children react to and try to relieve stress such as pain. Active coping includes strategies to reduce pain or the impact of pain (eg, going to school despite pain) and passive coping includes distancing oneself from the pain (eg, relying on others to deal with pain). Passive coping is associated with more suffering. One particular form of coping is catastrophizing, which is the tendency to magnify the negative aspects of pain while feeling helpless in the face of pain. Catastrophizing is associated with higher levels of pain and depression in children. Avoidant copers withdraw from social interactions and have worse outcomes whereas engaged copers what seek social support and have active coping mechanisms fare better. This shows the role of social support in improving pain in FAPD.
Role of parents in FAPD
Pain in the children affects the parents and can induce anxiety and somatisation in the parents as well. Parental anxiety is due to the fear that the child is suffering from some unrecognised disease or that it signifies a serious disease. Parents often reject that the child is suffering from a functional pain. Parents also teach the children how to react to their symptoms, and children also learn by observing how adults behave when they are sick. Parents who have IBS are more likely to have children with FAPD. When a parent stays home expecting special attention even when suffering minor symptoms, the child is likely to be hypervigilant about their own symptom and stay back from school. The more family members with similar pain, the more suffering is reported by children. parents can influence their child’s pain and pain outcomes through both modeling illness behaviors and reinforcing illness behaviors.
The final word
It is clear that psychological factors play an important role in childhood FAPD. Although it remains to be established if psychological factors can cause FAPD, there is large evidence these factors influence the exacerbation and maintenance of pain as well as pain‐related disability. It is important to identify and address these issues while treating childhood FAPD.