(a)
Predisposing factors
These factors include the following:
Childhood trauma—This constitutes physical, emotional, or sexual abuse by parents or caregivers as well as neglect or lack of care. Persons with a history of trauma in childhood are thought to focus on bodily symptoms such as pain as a means of avoiding the cognitive and emotional processing associated with the traumatic experiences.
Childhood experience of illness—The children with a history of physical illness in childhood that is reinforced by anxious parents may increase the focus on bodily symptoms, anxiety, and illness behavior in adulthood as well as resorting to maladaptive coping behaviors.
Temperament/Personality—Negative affectivity or neuroticism personality factors have been found to be associated with somatic preoccupation, illness behavior as well as symptom misinterpretation in persons with somatic complaints.
(b)
Precipitating factors
These factors include the following:
Physical illness—Recent physical illness may increase anxiety related to health, which may precipitate development of multiple somatic complaints such as recurrent headaches.
Life events—Somatic symptoms such as pain may be preceded by life events such as trauma, interpersonal difficulties, or financial problems. This relationship between life events and development of somatic illness may be medicated by factors such as anxiety or depression or body focus to avoid unwanted cognitive and emotional processes associated with those life events.
(c)
Maintaining factors
These factors include the following:
Illness beliefs—Some beliefs about physical health and illness have been found to be associated with maintaining somatic complaints such as headaches. Example of such beliefs include those involving beliefs about inability to tolerate stress or having vulnerability to illness, beliefs about importance of maintenance of vigilance about symptoms, cost of illness or death, danger of anxiety as well as all or none beliefs about personal competence.
Illness behaviors—Certain illness behaviors such as avoidance of certain stimuli or physical exercise, compensatory behaviors, repeated medical consultations, and body checkups may maintain somatic illness or symptomatic distress.
Cognitive factors—Excessive rumination or worry about causes, implications, and treatment of symptoms, and physical health often maintain somatic complaints experienced by persons. A selective attribution bias for information confirming symptoms has been found to be associated with maintenance of somatic symptoms.
Affective factors—Emotional distress such as anxiety and depression has been associated with increase in rumination, catastrophizing, and worrying about the pain symptoms as well as increase in illness behavior and increase in other pain symptoms.
Social factors—Excessive reassurance/care-seeking from significant others may increase somatic preoccupation. The stigma associated with emotional distress and psychological illness by others may reinforce assigning physical causes to symptoms as well as increase illness behaviors. Increase in visits to doctors may at times increase misattributions regarding symptoms especially if causal factors associated with somatic symptoms are explained in an ambiguous way to the patient.
Physiological factors—Certain physiological factors such as sleep and appetite changes, organic illness, and medication overuse may maintain the illness behavior, associated emotional distress as well as cognitive misattributions and hence, exacerbate somatic symptoms.
9.3 Case Vignette
Ms. A, a 14 year old girl, student of class 9, belonging to middle socioeconomic family with no family history of psychiatric illness, presents with headache with nausea and vomiting. She reports having difficulty in attending school and concentrating on her studies due to the headaches. She has been diagnosed with having migraine by the physician and has been prescribed some medication. She has been referred to the consultant psychologist for non-pharmacological management.
9.4 Assessment
The goals of assessment include the following: firstly, to establish whether the possibility of any physical disease has been ruled out; secondly, to engage the patient in a therapeutic process; thirdly, to gain information regarding the cognitive behavioral formulation of the presenting complaints; and lastly, to understand the medical and psychological conditions that the adolescent is suffering from.
The assessment tools employed in assessing an adolescent with pain are discussed below:
(a)
Interview—This involves interviewing the adolescent and informant regarding the symptoms, history of development of symptoms, personality/temperament of the child (easy going, difficult), any associated medical conditions, history of psychiatric illness in family, and developmental history. A detailed account of the chief complaints pertaining to the site(s) of pain, duration as well as precipitating stressors associated with it is taken into account. The medical investigations as well as comorbid pathology should also be elicited. At times, a model, i.e., a caregiver with pain behavior may be present in the patient’s environment. Information regarding that should be noted. This can also be supplemented with a mental status examination (appearance, perception, thought, mood, affect, thought, gait, attention and concentration, eye contact, higher mental functions, and insight).
(b)
Self–report measures—Self-report measures can be considered as the most valid approach to pain measurement. Although self-report measures exist in verbal and nonverbal formats, both require sufficient cognitive and language development to understand the task and generate an accurate response. Verbal self-report measures include structured interviews, questionnaires, self-rating scales, and pain adjective descriptors. Nonverbal measures include facial expression scales, Visual Analog Scales (VASs) (Fig. 9.2), and drawings. Quantitative scales include the VAS and Colored Analog Scale (Barretto et al. 2004). Multi-dimensional pain measures help to assess pain experience, disability, and quality of life. These include the Bath Adolescent Pain Questionnaire (Eccleston et al. 2005). The McGill Pain Questionnaire (MPQ) may be used with older adolescents (Melzack et al. 1975).
Fig. 9.2
Example of Visual Analog Scale
(c)
Pain diary/ABC chart—A pain diary or an ABC chart is a way to keep track of the situations, thoughts, and feeling. This helps to elicit the negative/automatic thoughts associated with pain sensations. This diary may be useful in identifying cognitive distortions and restructuring them. Example of the pain diary of Ms. A is as follows:
A (Activating event) | B (Beliefs) | C (Consequences) |
|---|---|---|
Trying to finish homework | I cannot understand anything | Headache, feeling irritated |
(d)
Observation The adolescents’ maladaptive patterns of emoting and behaving can be observed and recorded while he/she is at home or school (teacher and parent reports), while waiting for the therapy session, and during the therapy sessions. These can be useful in helping the adolescent learn adaptive coping patterns to cope with pain and any associated disability as well as for social skills training.
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