Commentary: Functional abdominal pain: another unexplained physical symptom

Roger Jones

Guy’s, King’s and St Thomas’ School of Medicine, King’s College London, UK. Correspondence: Professor Roger Jones, Department of General Practice & Primary Care, 5 Lambeth Walk, London SE11 6SP, UK. E-mail: roger.jones{at}kcl.ac.uk

Hannay’s concept of the symptom iceberg is widely recognized.1 Well-being and asymptomatic disease are located at the broad base of the iceberg, or pyramid, above which lies that section of the population who are symptomatic but do not seek medical advice for their symptoms—the non-consulters. Symptom diary studies in the UK and the US have suggested that as few as 1 in 40 symptoms ever becomes the subject of a formal medical consultation. Instead individuals employ a range of strategies, involving formal and informal advisers and care-givers, before entering the process that turns people into patients. Above this self-care segment is primary care—first-contact care provided by general practitioners (GPs), emergency departments, other community-based health care professionals and, increasingly, telephone and web-based health advice services such as NHS Direct and NHS Direct on-line. Approaching the apex of the pyramid, patients may enter secondary and, finally, tertiary care, where they represent a highly-selected minority of the patient population.

This model encourages us to consider not only the descriptive and aetiological epidemiology of symptoms and disorders, but also to think about the factors leading to both illness onset and illness declaration, the recognition of symptoms, the inter-relationships between social, psychological and physical factors, the interplay of symptoms and health beliefs, the modulating effects of advice from kinship and kithship networks, the influence of health information, and the configuration of healthcare services which may encourage or obstruct access to care.

Many of these issues have been studied in relation to gastrointestinal symptoms. Castell has applied the ‘iceberg’ model to gastro-oesophageal reflux disease2 and the factors contributing to the decision to consult for dyspepsia and irritable bowel syndrome (IBS) have also been studied. These conditions have 1-year population prevalences of around 40% and 20%, respectively,3,4 but only one-third to one-quarter of individuals with these problems consult a GP. In the case of dyspepsia the impact of pain severity as a determinant of consultation is greatly outweighed by patients’ concerns about the possibility of serious disease, including cancer and heart disease.5 In IBS pain severity plays a more prominent role, but anxiety and depression and fear of cancer are also important factors contributing to the decision to consult.6

Much less is known about the origins, incidence and experience of abdominal pain in the community, and Halder et al.’s paper from Manchester raises a number of interesting questions about the prevalence, incidence and causality of abdominal pain in the general population, and generates further questions about the impact of psychosocial factors on the onset and declaration of organic and non-organic abdominal syndromes.7 Although the baseline prevalence of abdominal pain appears low, particularly when considered in relation to the figures for dyspepsia and IBS, this is largely explained by their chosen definition of abdominal pain, namely pain lasting at least 24 hours. This is quite a restrictive definition, given the cyclical nature of many abdominal symptoms and the intermittent nature of more ‘organic’ abdominal pain, such as ulcer-like and reflux-like dyspepsia. However, some support for this population estimate comes from a larger survey of chronic pain in the community, conducted in the Grampian region of Scotland, in which over 50% of patients self-reported chronic pain, but to which figure abdominal pain contributed only a tiny proportion.8 Halder and colleagues followed up their community sample for 12 months, and found that approaching 5% of men and women reported new onset abdominal pain at follow-up. These individuals were more likely to have high scores on fatigue, illness behaviour, and health anxiety scales, and multivariate analysis indicated that higher levels of psychological distress and prior illness behaviour were the major independent predictors of the onset of new abdominal pain. Although the numbers were small, it appears that only one in seven of these people consulted their GP with any kind of gastrointestinal symptoms (n = 8), and that five of these people had diarrhoea and three were described as having non-specific abdominal pain. These data are consistent with the very low incidence of new-onset dyspepsia in a 1-year follow-up of a community sample in the south of England.9

The Manchester group also found that back pain was positively associated with the onset of abdominal pain, and have gone on to speculate that not only were more of these patients suffering from a functional gastrointestinal disorder (FGID), but that the FGIDs form part of a continuum of non-physical symptoms which also include fibromyalgia, tension headache, chronic fatigue, atypical facial pain and non-cardiac chest pain.7 Publications in the psychological literature increasingly support this view, although caution is now expressed about the use of the term ‘somatization’ or the search for a single aetiological factor.10 Instead, the emphasis is on the potential contributions of biological, psychological, interpersonal and healthcare factors, and the need to construct an individualized aetiological formulation for each patient with unexplained chronic pain. Iatrogenic factors are particularly potent in the development and persistence of medically unexplained symptoms; doctors who appear uncertain about the problem and are unable to provide an explanation, who fail to convince patients that their complaints are regarded as genuine, who provide reassurance without a positive explanation, give ambiguous and contradictory advice, and indulge in excessive investigation and treatment are likely to launch their patients into a successful illness career.11

The managements of patients with unexplained physical symptoms, including FGIDs, hinges on adequate assessment and the choice of an appropriate intervention. The identification of patients’ health beliefs and concerns about their symptoms, with an open discussion of ‘organic’ and ‘functional’ diagnoses, combined with appropriate examination and investigations and a full explanation of the (usually negative) findings, are essential. In particular it is important to understand the patient’s reaction to their symptoms and the way they cope with them, and to look carefully for psychiatric and social problems and family factors. The findings in the Manchester paper clearly support this approach, and given the importance of the psychosocial factors identified in their survey, their findings also have implications for the design of therapeutic interventions in non-specific abdominal pain.

The low incidence of abdominal pain in the population reported in this study may deter further research into the natural history of the symptoms in the community and the subsequent design of intervention trials, because of the size of the population base required to identify a study cohort large enough for meaningful analysis. However, an alternative approach might be to assemble a cohort of patients with new-onset symptoms affecting other organ systems, including back pain, non-cardiac chest pain, generalized muscle and joint pain, tension headache, and atypical facial pain. The natural history of these symptoms could be documented in a longitudinal study and, with more information available from psychometric testing and the application of some of the psychosocial measures used by the Manchester group, general and system-specific interventions could be designed and trialled.

References

1 Hannay D. The Symptom Iceberg. London: Routledge and Kegan Paul, 1979.

2 Castell DO, Johnston BT. Gastroesophageal reflux disease. Current strategies for patient management. Arch Fam Med 1996;5:221–27.[Abstract]

3 Jones R, Lydeard S. Prevalence of symptoms of dyspepsia in the community. BMJ 1989;298:30–32.[ISI][Medline]

4 Jones R, Lydeard S. Irritable bowel syndrome in the general population. BMJ 1992;304:87–90.[ISI][Medline]

5 Lydeard S, Jones R. Factors affecting the decision to consult with dyspepsia: comparison of consulters and non-consulters. J Roy Coll Gen Pract 1989;39:495–98.[ISI]

6 Kettell J, Jones R, Lydeard S. Reasons for consultation in irritable bowel syndrome: symptoms and patient characteristics. Brit J Gen Pract 1992;42:459–61.[ISI]

7 Halder SLS, McBeth J, Silman AJ, Thompson DG, Macfarlane GJ. Psychosocial risk factors for the onset of abdominal pain. Results from a large prospective population-based study. Int J Epidemiol 2002; 31:1219–25.[Abstract/Free Full Text]

8 Elliott AM, Smith BH, Penny KJ, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999; 354:1248–52.[CrossRef][ISI][Medline]

9 Jones R, Lydeard S. Dyspepsia in the community; a follow up study. Brit J Clin Pract 1992;46:95–97.[ISI][Medline]

10 Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999;354:936–39.[CrossRef][ISI][Medline]

11 Mayou R, Farmer A. Functional somatic symptoms and syndromes. BMJ 2002;325:265–68.[Free Full Text]





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