Behavioral and Psychological Approaches

Although pharmacologic therapy has a valuable role in these patients, it is also clear that a successful outcome requires taking into consideration several, equally important, factors. As explained previously, chronic pain cannot be viewed as a purely neurophysiologic phenomenon and has many other facets, the most important of which is the psychological dimension, consisting of cognitive, emotional and behavioral processes. The combination of these factors results in functional disability, a third dimension of chronic pain that is often ignored. Several psychological techniques have been used with good effect in the management of a variety of chronic pain syndromes, although specific evidence for their efficacy in chronic abdominal pain syndromes is generally lacking. Operant interventions focus on altering maladaptive pain behaviors, such as reduced activity levels, verbal pain behaviors and excessive use of medications. Cognitive behavioral therapy extends beyond this to also include cognitions or thought processes, based on the premise that these closely interact with behavior, emotions, and eventually physiological sensations (ie, the biopyschosocial continuum); altering one of these components can therefore result in changes in the others. Positive cognitions include ignoring pain, using coping self-statements, and indicating acceptance of pain. Negative processes include catastrophizing (ie, viewing the pain as the worst thing in the world and believing it will never get better). Biofeedback and relaxation techniques teach patients to use control physiologic parameters and decrease sympathetic nervous system arousal. Hypnosis attempts to bring about changes in sensation, perception or cognition by structured suggestions and has recently shown promise for patients with IBS. Group therapy exposes patients to others with similar problems and allows them to feel less isolated. Dynamic (interpersonal) psychotherapy attempts to reduce the physical and psychological distress caused by difficulties in interpersonal relationships.

It is, therefore, highly desirable, and probably necessary in some cases, to involve a clinical psychologist in the care of these patients. Indeed as with somatic pain clinics, one can make a case for a broader team approach to chronic abdominal pain, involving other specialists such as anesthesiologists, occupational therapists, and pharmacists. However, in the absence of such an infrastructure, the gastroenterologist needs to assume some key responsibilities in this regard particularly in the form of ongoing patient education about the relationship of their symptoms to both underlying pathophysiology as well as to psychosocial factors. There is a chapter on exaggerated and facticious disease (see Chapter 42, "Factitious or Exaggerated Disease").

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