ADDRESS: 1 100 West Michigan Street, Indianapolis, Indiana 46207.
PEDIATRICS, Vol. 40, No. 1, July 1967
84
DIAGNOSIS
AND
TREATMENT:
PSYCHOGENIC,
RECURRENT,
ABDOMINAL
PAIN
Morris Green, M.D.
Department of Pediatrics, Indiana University School of Medicine
INTRODUCTORY NOTE : A discussion of some common problem of pediatrics
regularly appears as the last article preceding the “Experience ami Reason”
section. Usually contributed by a member of the Editorial Board, each of
these short papers is intended to present his current practice in regard to
diagnosis or therapy or both. The Editor will welcome suggestions for
de-sirable topics.
ECU1IHENT abdominal pain represents a frequent cause for medical
consulta-tion.1 At least 1 school child in 10 suffers from this complaint.23 Slightly more corn-mon in girls than in boys and unusual before the age of 5, recurrent abdominal pain has its greatest incidence in children 9 to 10 years of age. In 1,000 unselected school children Apley’ found the complaint to occur more frequently in girls (12.3%) than in boys (9.5%); more than one fourth of all girls at age 9 were affected.
Both organic and psychogenic etiologic possibilities need be considered together in each such case. The present discussion will be largely concerned with the latter. It is intended that a subsequent article will be concerned with organic abdominal pain.
CHARACTERISTICS OF PSYCHOGENIC,
RECURRENT, ABDOMINAL PAIN
About one half of the children whose pain is psychogenic will have been sympto-matic less than 1 year at the time of consul-tation; others will have had complaints for 1 to 5 years. Some children experience six or seven episodes a day while others one a week or one a month. Although this symp-tom may be related directly to stressful sit-nations, this relationship is uncommon. A temporal relation to meals is rare, and the pain almost never awakens the child from sleep. Individual attacks are usually 5 to 30
minutes in length ht ma’ persist for hours.
Episodes usually began gradually rather than abruptly. The pain is generally con-stant and mild or moderate rather than colicky and severe. Descriptions are vague: “It just hurts,” “It feels funn’,” or “I don’t
knov.” The complaint is poorly localized to the epigastric or periumbilical regions in most patients, but it is reported by a few to change from place to place or to radiate in a bizarre manner. Nausea, pallor, vomiting, dizziness, headache, or faintness may pre-cede or accompany the pain.
SOME GENERAL QUESTIONS TO KEEP IN MIND IN THE MEDICAL INTERVIEW
Why did they come in now? Whose idea was it to come?
In some instances the complaint is used to see the doctor when ‘the parent is really more disturbed about the behavior of the
child or about problems in family relation-ships. A mother anxious about her own health may consciously or unconsciously use this indirect approach to obtain help for herself. Some children are brought reluc-tantly in response to pressure from the school attendance officer or from a grand-parent persistently worried about serious
disease. In those families in which chronic physical or emotional complaints are
85
be prompted by some new crisis which has disturbed their shaky equilibrium.
How did it start? When does it occur?
The temporal relation of the complaint to important events in the life of the child and his family needs to be determined. This chronology may have to be established by the physician himself since the parents may not correlate these events with the onset or recurrence of the abdominal pain, especial-ly in the initial interview. Some parents, preoccupied with their own difficulties, seem unaware of their children’s problems; for many others, a relation between the life experiences of the child and abdominal pain is a novel idea.
What does the parent think is wrong?
Most parents believe the pain to be or-ganic
(
e.g., appendicitis, ulcer, “female troubles,” or spastic colitis), even if theycannot suggest a specific disease : “One thing I know, it’s not mental! That boy has real pain!” Even those parents who suspect that the symptom is psychogenic are usual-ly unable to suggest directly specific etio-logic factors.
What are the conscious gains?
As a result of the pain, the child may gain increased attention and solicitude from his
parents
(
e.g., be able to sleep with his mother)
or gain some control of his situa-tion(
e.g., keep his parents from fighting or avoid separation from his mother).Why was this symptom selected?
Although its pathogenesis is not clear, ab-dominal pain appears unconsciously to less-en anxiety and assuage guilt.’ The selection of this specific physical complaint may be due to an identification with an important member of the family who has similar symptomatology.
What do the parents expect?
It is important to gain an idea of what special examinations and treatment the
par-ents and child anticipate. Knowledge of
what the parents really want, expect, and are ready to accept, while not determining the details of the work-up and treatment, permits the physician to present his medical evaluation and recommendations meaning-fully.
SOME FACTORS TO LOOK FOR
The considerations listed here, while not specific for patients with recurrent abdomi-nal pain and, indeed, present in many chil-dren without physical symptoms, appear to be etiologically relevant. Usually, multiple factors are present in the child’s current sit-uation or past experience.
Death or Separation
1. The history, the child’s anticipation, or his fantasy of the death of an important
ierson in his life, especially one living in the same household.
2. The anticipated or actual separation or divorce of the parents.
3. The desertion of the family by mother
or father or the threat of such desertion.
4. The absence or anticipated absence of the father or an older brother clue to mili-tary service or imprisonment.
5. Extended absences of father or mother for vocational or social reasons.
6. The child’s fear of his own premature death because of a past, life-threatening
5
7. Chronic, life-threatening disease in the child. With the complaint of abdominal pain, the child and parent have a definable symptom to take to the doctor for reassur-ance.
Physical Illness, Hypochondriasis, or
Chronic Handicap in Parents or Siblings
ABDOMINAL PAIN
in controls. The highest such incidence was in the mothers.
Marital Discord
Marital discord may be characterized by
threats, quarrels, fights, and infidelity.
Psychologic Illness in Parents
Illness in parents such as chronic depres-sion or alcoholism, may cause the child to worry that his mother may commit suicide or his alcoholic father may have a fatal auto accident.
Unsatisfying Parent-child Relationships
Unsatisfying relationships may be cvi-denced by overly-severe discipline, favori-tism for another child, excessive pressure for accomplishment, inconsistent discipline,
too many prohibitions, or lack of attention to the child as an individual.
Parental Preoccu potion with Illness
While in some families physical and emo-tional complaints tend to be ignored or not perceived, they are overemphasized in others. In the latter, almost everyone is being seen by physicians and taking a var-iety of medicine and vitamins. As part of this pattern of familial hypochondriasis, the mother takes the child repeatedly to physi-cians for indications that seem proper to her but trivial to the doctor. An occasional mother, who appears to have a compulsion to find something wrong with her child, will repeatedly bring him for medical attention, usually to many doctors and for a host of complaints, including recurrent abdominal pain, because of her certainty that the child has an elusive, serious disorder even though a succession of doctors has been unable to make a diagnosis.
Difficulty in Handling Aggressive,
Hostile, or Sexual Feelings
The thought or the expression of aggres-sive, hostile, or sexual feelings may cause considerable guilt in some children, espe-cially in those who are docile, repressed, and non-aggressive. This may be a
prob-1cm, especially if the person towards s’hom such feelings are directed is chronically ill, injured, or has been seriously sick. The child may resent the heavy demands made by his parents but be unable to express his anger directly. One child became so upset after striking another girl that she hid under her bed all day. Thoughts of a sexual nature may also cause prepubertal and ado-lescent children to conclude that they are bad. Considerable anxiety may accompany normal development during adolescence, especially if the child has received little preparation for physical and physiologic changes.
Inappropriate Sleeping Arrangements
Some examples of poor sleeping arrange-ments are a 9-year-old girl sleeping in the same room as her 17-year-old brother, an 8-year-old boy sleeping in the same bed as his grandmother who is thought to have a malignancy, or children sleeping in the same room as their parents.
School Problems
Intellectual limitation or specific learning disabilities are examples of problems in this area. The child with school phobia also fre-quently complains of abdominal pain to avoid going to school.
ORGANIC CONSIDERATIONS IN RECURRENT, ABDOMINAL PAIN
Gastrointestinal tract investigation should “nile out” the possibility of: pel)tic ulcer, reduplication of the bowel, Meckel’s di-verticulum, malrotation, polyps, regional enteritis, ulcerative colitis, mesenteric cyst, constipation, and parasites. Urinary tract anomalies, cholelithiasis, chronic hemolytic anemia, and epileptic equivalent states (ex-tremely rare) should also be considered.
The History
MANAGEMENT
ARTICLES 87
psychogenic, or both. The physician is most effective in helping when he considers both organic and psychologic possibilities to-gether; the practice of “ruling-out” organic disease first tends to be both anti-diagnostic and anti-therapeutic if the difficulty is, in-deed, psychogenic. A diagnosis of “psycho-genie abdominal pain” requires evidence of significant psychopathology rather than the absence of organic disease. In those cases in which the physician feels he is not
obtain-ing a frank statement from the parents, he may need to question them directly at some point about alcoholism, marital infidelity, or parental depression.
The affect of the parent and the patient during the interview and physical examina-tion is of diagnostic interest. Some are blandly indifferent, others are clearly de-pressed, and a few appear to enjoy talking about their complaints.
The Physical Examination
A conspicuously meticulous physical cx-amination has important psychotherapeutic value in patients with recurrent abdominal pain. Even if the history does not suggest an organic lesion, the physician, the child, and the parent need to be satisfied as to the absence of abnormal physical findings.
Since this appraisal may seem more impor-tant to the child and his family than the his-tory, a cursory examination or no examina-tion may imply that the evaluation is gross-ly deficient or that the complaint is not
re-ceiving serious consideration. Once the physical examination has been accom-plished, however, there is no need to bela-bor the point by frequently repeating it un-less symptoms change or one has not exam-med the child during an attack. Abdominal tenderness, distention, or muscle spasm are generally not found in patients with psy-chogenic abdominal pain.
Procedures
The extent of laboratory and roentgeno-graphic investigation depends upon the physician’s experience, judgment, and ways of dealing with problems that are not
clear-cut. Such investigations are neither a sub-stitute for an adequate history nor a proper way to quiet the demands of the parents. The physician must have the self-con-fidence, based on training and experience,
to know when certain procedures are
indicated and not to succumb to what Apley has termed a “witch hunt” in which “if one test is negative, more and more may be invoked.” On the other hand, the work-up should be such as to permit the physi-cian to be comfortable with its complete-ness. The physician may well be guided by the advice of MacKeith and O’Neill, “The process of excluding organic disorders should be tempered with clinical common sense.”
Examinations which may be commonly indicated in these children include a blood count, urinalysis, perianal swab for pin-worms, and study of stools for ova, para-sites, and occult blood. During an episode of pain, it may be helpful to obtain a plain film of the abdomen. Other procedures
(
e.g., upper gastrointestinal series, barium enema, gallbladder series, or intravenous pyelogram)
may be undertaken as appears indicated by the history and the nature of the pain. An electroencephalogram would be only rarely indicated. Since their indica-tions are not always sharply defined, it is difficult in some cases to decide whether a gastrointestinal study or an intravenous py-elogram should be done.A brief explanation why a procedure an-ticipated by the parents is not necessary precludes the assumption that the doctor has unwittingly or carelessly overlooked an important diagnostic measure. While some parents request and, at times, successfully induce the physician to order examinations of questionable diagnostic value, others are annoyed by what they consider needless
duplication : “My child has already had every test and examination in the book and still no one knows what is wrong!”
88 ABDOMINAL PAIN
and additional visits may be required. In a few patients the cause of the pain never be-comes clear. In the absence of data sup-porting a psychologic cause, it is wise to keep the possibility of undetected organic disease well in mind.
Treatment
Treatment begins when the patient en-ters the office and should procede simulta-neously with diagnosis. Because of the
(luestions raised in the interview, the par-ents and child should be aware that the physician is considering psychogenic as well as organic possibilities. When such considerations are introduced only after studies for organic disease have been corn-pleted or when the child has been seen pre-viously by many doctors and subjected to a number of procedures and treatment
(
e.g., for a possible ulcer)
, the outlook for symp-tom alleviation is guarded. Similarly, pa-tients and parents who are sent to the doe-tor(
e.g., by the school because the child has missed so many classes)
are difficult to help since they do not talk freely and are disinterested in further appointments. If there is no evidence for organic disease, the physician should state so conclusively, even if this is not readily accepted by the parents. Even when reassuring to the parent and child worried about an organic lesion, this statement may not relieve the symptom. It would appear that the child does not “grow out of” the complaint; in many instances, it continues to manifest itself in what Engel has termed the “pain-prone patient.”4The degree to which the patient can be helped and the time required to accomplish this is variable. The pediatric interview is the most important therapeutic instrument. In some cases, the symptom disappears dra-matically after one visit, either because the interview has provided the opportunity to talk fully to the physician about themselves and their family and to express their feel-ings, thoughts, and fears or because the parent and child have thus become aware of causative relationships. Relief of the symptom does not, however, mean that the
underlying problem has been solved. Other families require several return visits and, perhaps, direct advice, e.g., return the child to school, obtain a special tutor for reading, change sleeping arrangements, stop physi-cal punishment, attempt to be more flexi-ble, reduce excessive demands and expecta-tions, permit expression of angry feelings, pay more attention to the child, reduce par-ental social comittments, place an aged grandparent in a nursing home, or obtain medical or psychiatric help for themselves. When the patient is over 8 or 9 years of age, family group interviews may be help-ful. Since many problems in these children are attributable to external stresses, changes in the environment often lead to significant improvement.
Because of the parents’ concern about the physical implications of the symptom, these patients are usually best managed initially by the pediatrician rather than the child
psychiatrist. The psychologic help which the former can supply may be acceptable while referral to the latter may be met by anxiety, anger, or rejection. The physician may wish to collaborate with a family ser-vice agency when confronted with prob-lerns in family relationships that need to be understood in relation to the patient’s corn-plaints. In some children, recurrent abdom-ma! pain, usually accompanied by other psychiatric manifestations
(
e.g., phobia), may be a prelude to a more serious emo-tional disorder. Such children need referralto a child guidance clinic as soon as this can be successfully accomplished. When adverse circumstances are unalterable
(
e.g., poor housing, inadequate income, death, desertion, divorce, or alcoholism)
, the doe-tor may consider with the parent and child how a better realistic adjustment can be made to a situation that will not change.Many families may question the necessi-ty of return appointments once it is
or-ARTICLES 89
ganically wrong, the doctor needs to mdi-cate with patience that, although careful study has revealed absence of physical dis-ease and further diagnostic studies are not indicated, he can appreciate their con-tinuing concern and will be glad to see them again whenever they wish. This ap-proach, while not curative, seeks to protect the child from needless examinations and procedures, including exploratory surgery.
Other families and children may not real-ly wish to give up the pain. While trouble-some in some respects, it seems to relieve
tension, to dull other even more painful feelings, or to be used consciously for see-ondary gain, e.g., to control a member of the family such as a wandering father. Un-less something else can be substituted the symptom will remain. The therapeutic ob-jective in these cases is help for the basic problem. Many of these families seem so accustomed to painful situations that ab-dominal pain is tolerable as long as it is known not to represent a life-threatening disease such as appendicitis. These families return for additional reassurance during
cx-acerbations of the symptom. Seeing the doctor and going through the process of the history and physical examination seems to be helpful, even if the precipitating crisis is not directly discussed.
Although adequately controlled studies are not available, drug therapy, although tempting to the busy physician as a time-saving device, is of limited or no usefulness, except for suggestion. Besides failing to deal with the basic problem, the prescrip-tion of drugs may contribute to both a con-tinning hypochondriasis and drug-depen-dency.
REFERENCES
1. MacKeith, R., and O’Neill, D. : Recurrent ab-dominal pain in children. Lancet, 2:278,
1951.
2. Apley, J.: The child with recurrent abdominal pain. Pediat. Clin. N. Amer., 14:63, 1967. 3. Apley, J.: The Child with Abdominal Pain.
Springfield, Illinois:: Charles C Thom:is, 1959.
4. Engel, C. L.: “Psychogenic” pain and the pain-prone patient. Amer. J. Med., 26:899, 1959.
5. Green, M., and Solnit, A. J.: Reactions to the
