Visceral pain-associated disability syndrome: a descriptive analysis

Pain-associated disability syndrome (PADS) is a recently defined term that describes patients with chronic pain whose restriction in daily activities appears disproportionately severe for the observable pathology. The aim of this study is to describe the features of a group of pediatric patients with abdominal symptoms fitting this diagnosis.

To identify factors associated with visceral PADS, we reviewed the records of 40 patients (18 males; age range, 7-21 years) with gastrointestinal symptoms severe enough to prevent school attendance or eating for 2 months or more. These patients, in whom pain was neither feigned nor self-induced, met the diagnostic criteria for visceral PADS, including failure of usual treatments and lack of a satisfactory organic explanation for the severity of the pain.

The dominant symptom was abdominal pain in 30 patients, regurgitation in 5 patients, nausea in 3 patients, and chest pain in 2 patients. All patients complained of pain or discomfort, and all met symptom-based criteria for one or more functional gastrointestinal disorder. Disordered sleep was a problem for 39 patients. Factors associated with PADS included learning disabilities, unrealistic goals in a perfectionist, high-achieving child, early pain experiences, passive or dependent coping style, marital problems in the home, and chronic illness in a parent. All patients had at least two associated factors, and a majority had four or more associated factors. Possible triggering events included an acute febrile illness in 20 patients, school change in 11 patients, trauma in 2 patients, death of a loved one in 2 patients, and sexual abuse in 2 patients. Before diagnosis, all patients underwent extensive negative evaluations. Nearly all patients had mental health evaluations that ruled out eating disorder and psychosis. Medical management had failed, and surgeries worsened symptoms. In a majority of patients, we identified a comorbid psychiatric disorder.

Evaluation of preteens and teens unable to go to school or eat because of unexplained incapacitating symptoms should include queries about factors associated with PADS. To treat PADS, medical and mental health clinicians must recognize pain as having both nociceptive and affective components and address treatment collaboratively. Invasive procedures and surgery reinforce the cycle of arousal and pain and are to be avoided. Age for the onset of PADS in the preteen and early teen years suggests that developmental issues play a role.