El Dolor Abdominal Recurrente de Causa No Orgánica en los Niños

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El tratamiento psicosomático del dolor recurrente de origen psicosomático aparece como una alternativa alentadora, aunque se requieren estudios aleatorizados y controlados para confirmarlo.

Autor:
Gösta Alfven
Columnista Experta de SIIC
Institución:
Karolinska University Hospital
Artículos publicados por Gösta Alfven

Recepción del artículo
14 de junio, 2010

Aprobación
2 de diciembre, 2010

Primera edición
22 de marzo, 2011

Segunda edición, ampliada y corregida
7 de junio, 2021

Resumen
El dolor abdominal recurrente de causa no orgánica es frecuente en los niños. La mayoría de ellos padecen de estrés negativo, que provoca el dolor. En este artículo se destaca la importancia de mantener una mentalidad abierta al momento de encarar la investigación de la etiología del dolor. Se presentan los criterios diagnósticos del dolor psicosomático. Se describen los síntomas físicos del estrés. Se indican las áreas importantes y los mecanismos del estrés en la mente y en el cuerpo. Se discuten dos estudios, uno publicado anteriormente y otro más reciente, acerca del tratamiento psicosomático. Los resultados son alentadores por lo que se recomiendan más investigaciones.

Palabras clave
estrés, trastorno psicosomático, dolor abdominal recurrente, tratamiento

Abstract
Recurrent abdominal pain of non-organic origin is common among children. The majority of these children suffer from negative stress causing the pain. In this article, the importance of an open-minded investigation of the etiology of the pain is underlined. The diagnostic criteria for psychosomatic pain are presented. Physical signs of stress are described. Important areas and mechanisms of stress in the brain and body are indicated. Two psychosoma treatment studies, one published earlier and a new one, are presented. The results are promising. Further studies are recommended.

Key words
Stress, psychosomatic disorder, recurrent abdominal pain, treatment

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Especialidades
Principal: Pediatría
Relacionadas: Cirugía, Diagnóstico por Imágenes, Diagnóstico por Laboratorio, Medicina Familiar, Medicina Interna, Salud Mental

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Gösta Alfven, Karolinska University Hospital CLINTEC Department, SE-145 01, Hallunda BUMM, Box 104, Norsborg, Suecia

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Expertos del Mundo

Especialidad principal:
Pediatría

Relacionadas:
Cirugía
Diagnóstico por Imágenes
Diagnóstico por Laboratorio
Medicina Familiar
Medicina Interna
Salud Mental

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Psychosoma treatment: a promising therapy for the child with psychosomatic recurrent abdominal pain

Introduction
Recurrent abdominal pain is a common problem in childhood [1], [2],[3]. The etiology is multiple. A surgical cause will be found in around 1% [4], [5], medical in around 10-20% [4], [6], [5], and psychosomatic in around 50% of cases [5].
For proper treatment, the diagnostic process is an important first step, not only to arrive at a diagnosis, but also to establish a good caregiver/care-receiver relationship, including understanding the patient and the family and collaboration concerning the child in pain. This will reduce tensions and worries connected with the pain for both the child and the parents. In cases with a psychosomatic etiology, this will be a good start for the understanding, care, and treatment of the child in negative stress.
Since it usually takes some time to arrive at a diagnosis, the diagnostic process should be a parallel search for a possibly organic or non-organic origin of the pain. This is especially true when a psychosomatic diagnosis is suspected. One pitfall is a not yet discovered organic disorder that lowers the threshold at which stress elicits pain, such as lactose intolerance, celiac disease, and allergy, so that a stress etiology of the pain is suspected erroneously.
Genetic, early experience, family and environmental factors, as well as inflammation and stress, all contribute to the development of a disease and its expression. This is well recognized as far as functional disorders is concerned, but bio-psycho-social factors are at stake also for organic disorders. Cornelius Celsus (25–30 B.C. – 45–50 A.D.) stated some 2000 years ago: “Above all, nothing has a single origin; rather, that which would appear to have contributed most to a particular effect must be regard as its cause.”
Non-organic pain is often called functional pain [7]. However, non organic recurrent pain often has a clear origin of long-standing negative stress, such as malfunction of the family, bullying in school, and anxiety caused by exceedingly high demands concerning school work [3]. If so, this is important to establish, and such a fact will also guide the decision-making concerning treatment.
Psychosomatics is an old concept regarding stress-induced symptoms, with origins in the 19th century. The concept became controversial during the 1980s due to misuse. However, with the use of strict diagnostic criteria, we have a tool for the differential diagnosis between pain, mainly due to negative stress, and what is not pain. In the latter case, a further quest for the organic cause is often appropriate. When negative stress is the main cause of the pain, a clear understanding of the etiology can be established, which lessens the worries, and gives us information concerning the treatment to choose.
The premises and criteria for a psychosomatic diagnosis are as follows [5]:
Premises
I. At least one episode of recurrent abdominal pain per month severe enough to affect the child’s activities for at least three months [8]
II. Organic disorder excluded
III. At least six of seven criteria defined here satisfied
Criteria
Onset or aggravation of chronic negative stress preceding the onset of recurrent pain
Pain parallel to chronic negative stress
Better state or pain free during periods of lessened/disappeared chronic negative stress
Acute stress induces pain
Most pain attacks related to acute stress
The child followed up for a long time, at least 6 months
Parents and responsible doctor agree about the diagnosis
The diagnosis is established when six out of the seven criteria are satisfied, and if five criteria are satisfied, the diagnosis will probably be psychosomatic.
Clinical Signs of Stress and Pain
It is a common belief that negative stress with pain will not show up as physical signs. This is not my experience. There are several signs that may support a psychosomatic diagnosis. One can suspect negative stress based on a pale face, a worried gaze, and tense face muscles. The muscles in the whole body react intensely to stress, activated by arousal and potentiated freeze and startle. This results in a pattern of tense and tender muscle in a so-called tender point stress pattern; see Fig. 1 [9]. When long-standing, the pain system reacts with sensitization leading to allodynia of the skin and gastrointestinal tract and, in a following step, to the development of fibromyalgia [10].
Treatment
In the case of an organic cause, appropriate surgical and medical intervention will reduce or take away the pain. In the case of an unknown non-organic etiology, cognitive therapy is recommended, which will help the child to better live with his/her pain [11]. Alternative treatment can also be of help, such as hypnotherapy, yoga, acupuncture, guided imagining, and transcutaneous electrical nerve stimulation (TENS [12].
Psychosomatic pain is a disorder of both soul and body. Stress and the pain process take place in both the central nervous system and the body. Treatment is probably optimal if directed at both soul and body.

Psychosoma treatment

Background
Psychosoma treatment is based on a present-day knowledge of how the body and the central nervous system react and interact in health and stress. The following neurological structures and systems are of crucial importance: i) The interoceptive nervous system informs the brain about the physiological status of the body [13]. The interoception becomes conscious in the insula and this is crucial for the understanding of self. The interoceptive system also connects to the prefrontal and cingulate cortex and this is crucial for decision-making [14]. ii)The mirror neuron system constitutes the basis for empathy and social interaction [15, 16]. iii)The amygdala, the insula, and the cingulate and prefrontal cortex are major areas for the perception and activation of stress [17], [18]. The pulsatile process of consciousness involves the thalamus and cerebral cortex as pivotal areas [19].
Although the main purpose of stress is to increase the ability of the organism to handle difficult, threatening situations, long-standing negative stress has negative consequences. It will lead to preoccupation with thoughts and feelings of the negative stress that result in malfunction of the interoceptive and mirror neuron systems, so that vicious circles between stress reactions in soul and body are induced and end up in a worsening of the disorder. Stress reduces the activity in the insula, with negative consequences for the regulation of health [20]. The activity of the mirror neuron system is negatively influenced by stress and thus the capacity for empathy and social interaction [16].
Four important goals in the treatment of psychosomatic pain are to decrease the negative stress, increase stress coping, and to positively stimulate both the interoceptive and the mirror neuron systems.
Theoretical Aspects
Psychosoma treatment has been developed and inspired from several sources including consulting psychology, cognitive behavioral therapy, and different physical therapies. Psychosoma treatment comprises four parts: (a) improving the child’s or adolescent’s relationship with the therapist, himself/herself and to the symptoms; (b) treatment of the body; (c) psychological treatment; and (d) improving the child’s psychosocial situation.
Reduction of the level of stress will have positive emotional and cognitive implications and will activate the mirror neuron system with increased empathy and social interaction. Gentle stimulation of the body reduces stress and will improve awareness of the physiological information from the body, which in turn will improve well-being and decision-making. Massage of the muscles and skin will stimulate the secretion of oxytocin and endorphin with an ensuing relaxing effect and reduction of pain. Relaxed, focused breathing will reduce stress and stimulate physiological awareness, and balance exercises will stimulate the interaction between the left and right sides of the brain via the corpus callosum and improve the balance between thought processes and emotions. Balance/ stability exercises may increase the physical and mental experience of stability, strength, psychological agency, and self-esteem. Physical activity that is individually adapted by a physiotherapist with knowledge of the interaction between body and soul may have a positive effect on stress reduction and increased physical self-esteem and well- being.
Two Studies on Psychosomatic Treatment: Material and Results
Material
Two studies on the effects of psychosoma treatment. The first one was made during 2004–2006 (Treatment Study 1) and was developed in collaboration with a psychologist specially trained in physiotherapy and under the supervision of an experienced psychologist with an interest in psychosoma treatment. Thirty-five children 6–18 years of age, 10 boys and 25 girls with mean pain duration of 33 (12–60) months were included in this study. The outcome measure was a pain score based on pain intensity and single-pain attack duration and frequency.
The effect of treatment was also evaluated by tender point stress (TP stress) score measurements at inclusion and follow-up. TP stress refers to a pattern of tender points in relation to the stress reaction of psychosomatic recurrent abdominal pain and headache; see Figure 1 [9]
Treatment Study 2 was conducted during 2007–2008. All children included satisfied the diagnosis of psychosomatic recurrent abdominal pain and received psychosomatic treatment* (21) Follow-up was done using the three outcome measures: pain-free at least the last month before follow-up, TP stress score (0–9), and tender point score with the pattern seen in fibromyalgia [22], i.e. TP FM score (0–18). The study included 15 children, mean age 12.1 (7–15) years, 3 boys and 12 girls, with a mean duration of abdominal pain of 25.2 (3–60) months. No control group was recruited. This is the first time the results from this study are presented.
* The treatment was administered by physiotherapist Ulrika Wallbing, who is trained in psychosoma therapy, and under the supervision of the same psychologist as in Study 1.
Results
At follow-up after a year Treatment Study 1 resulted in a diminished pain score from 7 (4–9) to 2.9 (0–5), which was significantly better compared to a group having only physiotherapy (n = 23) (P < 0.05) and another group (n =18) receiving care “as usual” (P < 0.05). The TP stress count was reduced significantly from a score of 6.4 (0-8) to 4.0 (0 - 8) (P< 0.01). For a detailed description, see [21].
At follow-up in Treatment Study 2, 11 children (76%) had been pain-free for at least one month, and the TP stress and TP FM scores had decreased significantly; see Table 1. The children without pain had significantly lower TP stress and TP FM scores; see Table 2.

Discussion
Neither one of the two studies was conducted according to the golden standard, i.e. the randomized controlled trial (RCT). The treatment of a disorder should be based on three premises: 1) the etiology of the disorder should be known, 2) there should be theoretical support for the effectiveness of the treatment; and 3) positive results of an RCT. For psychosomatic treatment, the first two premises have been satisfied. Prolonged negative stress can cause recurrent pain and we know how stress that causes disturbance in the brain and body can be reduced. Psychosomatic treatment is aimed at diminishing negative stress and utilizing neurobiological knowledge. The two studies presented here in a shortened form support the effectiveness of psychosomatic treatment. Improvement was measured as change in pain score and no pain for one month respectively, and TP stress score from inclusion to follow up, and for the second study also as change in TP FM score from inclusion to follow up.
Limitations
None of the measurements of pain, the pain score in Study 1 and free of pain for one month in Study 2, have been validated, and reliability has not been tested. TP stress has been tested for reliability [9] and for validity [21] and so has fibromyalgia [22].
The two studies are relatively small. The results need to be confirmed in an RCT.

Conclusions
For children with psychosomatic recurrent pain, psychosomatic treatment appears to offer promising help. An RCT is recommended to confirm this.

Bibliografía del artículo
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El Dolor Abdominal Recurrente de Causa No Orgánica en los Niños

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