Cognitive Behavior Therapy for the Treatment of Recurrent Abdominal Pain

This article outlines the rationale and use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. It begins with a conceptualization of the social learning perspective of RAP, and then covers the relationship between childhood social learning and adult and childhood illness behavior. Studies that have utilized a cognitive behavior therapy approach for treating adult pain are summarized. Finally, specific cognitive behavior therapy trials for treating RAP, as well as moderators of treatment effectiveness, are discussed. Keywords: recurrent abdominal pain (RAP); pain; children; illness behavior; social learning As has been discussed elsewhere in this issue, cognitive behavior therapy for IBS symptoms includes assessment and treatment of the behavioral, cognitive, and physiological phenomena associated with gastrointestinal symptoms and "illness behavior." Illness behavior is a term that refers to the way people perceive and react to somatic sensations that might signify disease (Mechanic, 1978). Illness behavior falls on a continuum, ranging from failure to notice such sensations or refusal to let even serious illness interrupt one's normal routine, to misinterpretation of normal somatic sensations as symptoms of disease and seeking unnecessary medical treatment for minor complaints. Both ends of the continuum are of concern to health care providers: Denial may lead individuals to postpone diagnostic investigations or to not adhere to medical regimens. Preoccupation with illness, on the other hand, creates a costly burden on the health care system (Drossman et al., 1993). This article will provide the rationale for and description of the use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. Less than 25% of physical complaints presented to physicians have known or demonstrable organic or physiological causes (Nezu, Nezu, & Lombardo, 2001). RAP is one of these many disorders in children that has significant societal and personal costs. Although 10% to 15% of children have RAP (Apley, 1975), children with RAP fall into the category of those presenting with such symptoms of unknown cause. A child is labeled with RAP when, in the absence of physical or laboratory findings, she/he has experienced at least three episodes of pain over a 3-month period that affect the child's activities (Apley & Naish, 1958). The term RAP encompasses a heterogeneous group of functional gastrointestinal disorders, such as irritable bowel syndrome, in which abdominal pain is a primary complaint (Boyle, 1997; Von Baeyer & Walker, 1999). New diagnostic criteria have been proposed for the various functional gastrointestinal disorders of childhood that constitute the subgroups of RAP, but these have not yet been validated (Drossman et al., 2000; Rasquin-Weber et al., 1999). Thus, current research in this area continues to use Apley's broad definition of RAP in patient selection, although efforts are underway to validate the diagnostic subgroups and to standardize tools for their identification (e.g., Walker, et al., 2004). RAP is the most common recurrent pain complaint of childhood (McGrath, 1990) and typically generates multiple clinic visits, extensive medical evaluations, and considerable school absence. Five years after their initial medical evaluation, adolescents and young adults with a history of RAP still have significantly more school and work absence and greater illness-related impairment than their peers (Walker, Guite, Duke, Barnard, & Greene, 1998). RAP is more common in girls than boys, is most prevalent during middle childhood (ages 8 to 11), and is frequently associated with a variety of vague, nonspecific symptoms such as fatigue, dizziness, and headaches (Murphy, 1993; Stone & Barbero, 1970; Walker, Garber, & Greene, 1991). …