Psychosomatics 40:277-285, August 1999
© 1999 The Academy of Psychosomatic Medine
Irritable Bowel Syndrome and Recurrent Abdominal Pain
A Comparative Review
Patrick Burke, M.B., B.CH., Ph.D.,
Melanie Elliott, B.A., and
Rachel Fleissner, M.B., B.S.
Received July 21, 1998; revised December 17, 1998; accepted December 29, 1998. From the University of Arizona Health Sciences Center, Department of Psychiatry, P.O. Box 245002, Tucson, AZ 85724–5002. Address correspondence and reprint requests to Dr. Burke at the same address; e-mail: burke{at}u.arizona.edu
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ABSTRACT
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Clinical findings on irritable bowel syndrome in adults and recurrent abdominal pain in children are reviewed to determine if what is known about each disorder can illuminate our understanding of the other. The evidence reveals striking similarities between the disorders in prevalence, course, medical and psychiatric comorbidity, family medical and psychiatric history, and association with life events. Continuity between the two disorders is also suggested by the results of follow-up and follow-back studies. The review shows the importance of a developmental perspective for understanding functional bowel disorders in adults and points to areas where further research would be useful.
Key Words: Irritable Bowel Syndrome • Pain
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INTRODUCTION
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Functional bowel disorders, defined as variable combinations of gastrointestinal symptoms that cannot be explained by structural or biochemical abnormalities, comprise the majority of conditions seen in the office practice of gastroenterology, and account for considerable morbidity and medical expense.1,2 The irritable bowel syndrome (IBS) is the most common functional bowel disorder seen in adults, but, despite much research, neither the cause nor the development of IBS is well understood.3 One recent review suggests that disruption of central control mechanisms that modulate the motility and sensation of the gut may be primary.3 In support of this hypothesis, patients with IBS may have an enhanced tendency to label visceral sensations negatively and may be hypersensitive to rectal distension.4,5 Furthermore, community studies suggest that most persons with IBS do not seek medical care,6 and psychological symptoms may determine if care is sought and the level of care that is pursued.7–10
Recurrent abdominal pain (RAP) is the principal functional bowel disorder seen in childhood, and is associated with depression, anxiety, and considerable psychosocial morbidity.11,12 Recent evidence also shows that a substantial number of children who have RAP meet criteria for IBS.13 Thus, comparative analysis of IBS and RAP may prove fruitful, since current knowledge of each disorder may further our understanding of the other and clarify why some persons with IBS show significant psychological symptoms. A comparison also enables us to examine the continuity between childhood and adult functional bowel disorders.
In this article, we examine current findings in IBS and RAP, considering definition, epidemiology, course and childhood history; medical and psychiatric comorbidity; family medical and psychiatric history; psychopathology and health care–seeking behavior; and the influence of stress and life events.
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DEFINITIONS
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IBS is characterized by at least 3 months of continuous or recurrent abdominal pain or discomfort that is relieved by defecation, and/or is associated with a change in stool frequency, or consistency of stool.7 In contrast to IBS, the classic definition of RAP does not include gastrointestinal symptoms other than recurrent abdominal pain. RAP is characterized by the recurrence of a minimum of three episodes of abdominal pain that is severe enough to hinder the child's activity, and usually occurs over a 3-month period.11 However, in a recent study of 171 children with RAP, 117 (68%) met the criteria used in adults to diagnose IBS.13
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EPIDEMIOLOGY
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IBS is present in 10%–22% of adults,2,14,15 with females more likely than males to have IBS.7 The prevalence of IBS declines in the elderly, but it is not known if this represents a true decline or if older persons are less prone to report symptoms.14,16 RAP occurs in 10% to 25% of children and adolescents.11,12,17 In one school-based study, the prevalence of RAP peaked at age 9 (21% of males and 30% of females) and decreased to 5% by age 17 in both genders.17 In a recent survey of middle and high school students, 75% of all students reported abdominal pain.18 The pain occurred weekly in 13%–17% of students, and affected activity in 21%. Fourteen percent of the high school students and 6% of middle school students reported IBS-type symptoms. The frequency and severity of pain and IBS symptoms was similar in male and female students.
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COURSE
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In a 10-year follow-up, symptoms persisted in 67% of IBS patients.19 In a community study, in which subjects were resurveyed at 12–20 months, less than two-thirds of persons with IBS reported symptoms at both times.20 In one study of RAP, 90% of 31 children reported that at least one further episode of abdominal pain occurred over a 9-month period.21 In a different study, 74% of children who had abdominal pain reported at least one further episode over a 5-year period.17 Long-term studies suggest that abdominal pain22 and gastrointestinal complaints23 persist into adulthood in some RAP patients. For example, in one study, 18 of 34 RAP children had symptoms that persisted into adulthood.23 Eleven of the 18 met criteria for irritable colon and 5 others met criteria for irritable colon and peptic ulcer/gastritis. In a follow-up study of a unique school clinic, children with stomachaches who were frequent users of school medical services continued to show similar symptoms in adulthood, and were high utilizers of medical services in adulthood.24
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CHILDHOOD HISTORY
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Persons with IBS often have histories of childhood abdominal pain;15 report making more visits to the doctor as children, compared with adults with IBS who had not sought care;25 recall more headaches, somatic complaints, and bowel symptoms during childhood than IBS nonpatients; and report greater parental attention to illness, more school absence, and more doctor visits than normal subjects.25 For example, IBS patients reported receiving more attention during childhood episodes of illness, compared with patients with peptic ulcer disease.26
Colic during infancy has been noted in close to one-third of RAP children,27,28 and has been reported in RAP children who had IBS as well as those who did not.13 Difficulties in pregnancy and neonatal distress have also been noted as correlates of RAP.28 In a pattern similar to that shown in the childhood of adults with IBS, RAP children and children with peptic ulcer disease reported receiving more encouragement for illness behavior associated with gastrointestinal symptoms than well children or children with psychiatric disorders.29
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COMORBIDITY
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IBS is associated with a number of medical and psychiatric disorders. We first review associations with medical conditions, followed by the association with psychiatric disorders. In each case, we contrast findings in IBS with findings in RAP. Finally, we discuss health care–seeking behavior and comorbid psychiatric symptoms.
Medical Comorbidity
Gastrointestinal Illness.
IBS shows considerable overlap with other functional gastrointestinal disorders, especially noncardiac chest pain and nonulcer dyspepsia (NUD).2,15,16 IBS has also been noted in 33% of 98 patients with ulcerative colitis in remission.30 In one study, IBS and peptic ulcer disease could be readily discriminated, but discrimination between IBS and inflammatory bowel disease was less clear.31 Children with RAP also frequently report gastrointestinal complaints other than abdominal pain, including dyspeptic symptoms similar to NUD found in adults.13,27
Fibromyalgia.
From 40% to 70% of fibromyalgia patients have IBS,32–34 and up to 65% of IBS patients have fibromyalgia.33 The prevalence of IBS is higher in fibromyalgia than in normal control subjects or patients with degenerative joint disease.35 Children with RAP have been found to have tense and tender muscles compared with control subjects.36 In addition, RAP children have a significantly lower pressure-to-pain threshold in many muscle groups compared with symptom-free children, but the former do not show a general increase in pain sensitivity.37 Thus, there may be a specific myofascial nocioceptive sensitivity in RAP children.
Dysmenorrhea.
In one study, dysmenorrhea was significantly more common in IBS patients than control subjects, although when IBS patients with psychiatric disorders were excluded, the difference became nonsignificant.38 In a second study, the prevalence of dysmenorrhea was similar in IBS patients and control subjects.39 A relationship between IBS and dysmenorrhea has also been inferred from observations made in women with dysmenorrhea. In one study, 61% of women with dysmenorrhea had a functional bowel disorder, compared with 20% of women without dysmenorrhea.40 In a study of women referred for abdominal pain, dyspareunia, or dysmenorrhea, 50%–52% had IBS.41 While dysmenorrhea has received little attention in RAP (probably because most subjects are in the stage of pre- or early puberty), there is evidence that dysmenorrhea is prominent in some RAP children by the time they reach adulthood.22
Headache and Migraine.
There is considerable evidence that headaches and migraine are common in both IBS and RAP. In one study, significantly more persons with IBS identified in a general practice survey had migraines (32%), compared with control subjects (18%).15 In another study, 31% of IBS patients had headaches, compared with 7% of control subjects.38 Interestingly, headaches were equally common in IBS patients (61%) and in persons with IBS who had not sought medical treatment (53%).9 Studies show that from 22%–50% of children with abdominal pain report headaches,17,42 and 31% of 306 children with RAP had a history of migraine (i.e., paroxysmal headaches accompanied by nausea), vomiting, and a desire to lie down.43 Headaches and migraine were also found to persist in RAP children who were followed into early adulthood.44
Chronic Fatigue.
Lethargy was noted in 88% of IBS patients in one study, and fatigue was a good discriminant of IBS from organic disease.45 Conversely, 63% of 1,797 persons with chronic fatigue met criteria for IBS.46 In one study, fatigue was noted in about one-third of children with RAP.47 Nineteen percent of the control group also reported somatic complaints, but the percentage with fatigue was not reported.
Psychiatric Comorbidity
Psychopathology.
Early studies suggested that 70%–90% of IBS patients are diagnosed with at least one psychiatric disorder.48,49 Depression, anxiety, and somatization are the most common disorders found. Compared with patients with inflammatory bowel disease, IBS patients had significantly more lifetime depression (61% vs. 16%), generalized anxiety disorder (54 % vs. 11%), phobias (50% vs. 11%), panic disorder (29% vs. 0%), and somatization disorder (32% vs. 0%).50 In a study of 35 IBS patients given structured interviews, 94% had a lifetime prevalence of any Axis I diagnosis, 34% had a lifetime prevalence of generalized anxiety disorder, 31% panic disorder, and 46% major depression.51
A specific link between IBS and panic disorder has been suggested.52 In one study, 16.7% of patients with panic disorder had IBS, compared with a zero prevalence of IBS in a control group.53 Persons with panic disorder also have significantly more gastrointestinal symptoms than those with no panic disorder, and the gastrointestinal complaints of panic disorder subjects fit the profile of IBS.54 Conversely, IBS patients have nonalimentary symptoms indistinguishable from panic disorder and hyperventilation syndrome.41
The relationship between IBS and psychiatric disorder has also been investigated by examining the prevalence of IBS in various psychiatric disorders. In one study, 59% of patients treated for dysthymia had a lifetime history of IBS, compared with 2% of medical outpatients who did not have an Axis I diagnosis.55 In a comparable study of outpatients treated for major depression, 27% had IBS, compared with 2.5% of a control group.56 In a different study, the point prevalence of IBS was 29% in patients with major depression, 37% in patients with generalized anxiety, and 11% in control subjects.57
Elevated rates of anxiety and depression have been described in children with RAP, and the most common of these disorders are depression, dysthymia, generalized anxiety disorder, and separation anxiety.21,58–62 In one study, the prevalence of psychopathology was the same in RAP as in children with gastrointestinal disorders of organic etiology and a psychiatric control group, but the prevalence was significantly greater in RAP than in healthy control subjects.47 In a community-based survey of middle and high school students, depression and anxiety scores were significantly higher in students with IBS symptoms than in students who did not have such symptoms.18 Although panic disorder has been specifically linked to IBS in adults, a similar association has not yet been reported in RAP. With regard to somatization disorder, the number and variety of somatic complaints required for the diagnosis may preclude the diagnosis in childhood or early adolescence. However, children with functional abdominal pain score higher on measures of somatic complaints than children with organic abdominal pain, and the number of somatic symptoms has been related to the chronicity of abdominal pain.60
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HEALTH CARE–SEEKING BEHAVIOR
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Only a minority of persons with IBS seek medical care, and females are more likely than males to seek medical attention for the disorder.7 However, one community study reported no significant gender differences in health care-seeking behvior among persons with IBS.6 In a school-based survey, only 9% of middle-school students and 10% of high-school students who reported abdominal pain had seen a physician in the past year.18 The aforementioned studies reviewed, which indicated an increased prevalence of psychiatric disorder among patients with IBS, were conducted in clinical settings. In contrast, persons identified through community surveys who have symptoms compatible with IBS do not show elevated rates of depression and anxiety.7,9,63 Patients seen in primary care settings may have levels of psychopathology midway between those who do not seek care and those who see specialists.7 It is now generally accepted that depression and anxiety are prominent primarily in IBS patients who seek medical attention and the associated psychological disturbance is related to health care seeking rather than to severity of IBS symptoms.8,9,10 In a study of middle and high school students, students who had seen a physician for abdominal pain reported being more distressed by their pain than were students with abdominal pain who did not see a physician.18 However, the relationship between depression or anxiety and seeing a physician was not significant.
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FAMILY HISTORY
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Family medical and psychiatric history can shed light on risk factors for functional bowel disorders, comorbidity, and health care-seeking behavior.
Family Medical History
Comparison of family medical history reveals that both IBS and RAP families are characterized by a family history of gastrointestinal problems. In one study, 33% of IBS patients had a family history of IBS, compared with 2% of normal control subjects.38 The difference remained significant when IBS patients with psychiatric disorders were excluded. However, in one family study there was no difference in the lifetime prevalence of IBS in first-degree relatives of IBS patients, compared with first-degree relatives of a control group of cholecystectomy patients.64 Interestingly, a family history of gastrointestinal problems is equally common in IBS patients (44%) and nonpatients with IBS (51%).9 These findings suggest that a family history of gastrointestinal problems is a risk factor for IBS, but not for health care seeking in IBS.
Gastrointestinal symptoms are found in a parent or sibling in 40%–50% of RAP cases,13 and are more common in the families of RAP children than in the families of control children.65 Fifty percent of the mothers and 46% of the fathers of RAP children had functional gastrointestinal disorders.27 A family history of peptic ulcer disease was also more likely to be present in families of RAP patients than in the families of healthy children.21 Children who have RAP only and RAP children who also met criteria for IBS have similar family histories of gastrointestinal symptoms.13 A family history of functional gastrointestinal disorders has been linked to a worse prognosis in RAP.21 Moreover, RAP children who were followed into adulthood and who had persistent abdominal complaints were more likely to have children with abdominal pain than adults who did not have abdominal complaints.23
In addition to having family histories of gastrointestinal problems, the families of RAP children are often characterized as being pain-prone.12 In one study, a family history of RAP was noted in 46% of family members of RAP patients.11 Nineteen percent of the parents of RAP children reported either current abdominal pain or a childhood history of abdominal pain.17 Mothers of RAP children more commonly have abdominal pain than fathers of RAP children.27
A family history of migraines is also common among RAP children.27,66 Thus, similiar to the findings in IBS, a family history of gastrointestinal problems, including abdominal pain, appears to be a risk factor for RAP.
Family Psychiatric History
The association between IBS and psychiatric disorder has been further explored by investigations of family psychiatric history. In one family study, the prevalence of psychopathology in relatives was surprisingly low, possibly reflecting the use of a single question to elicit family history of psychiatric disorder.67 In another study, the lifetime prevalence of psychiatric illness was higher in the first-degree relatives of adults with IBS than in the relatives of patients undergoing cholecystectomy.64 However, the lifetime prevalence of IBS was not different in the two groups of relatives. Thus, there was no significant association between IBS and psychiatric illness in the first-degree relatives of IBS patients. Since a family history of psychiatric disorder is a risk factor for psychopathology, and psychopathology, in turn, is linked to health care seeking,8,10 the authors suggest that their findings are consistent with the view that health care seeking in patients with IBS is associated with psychiatric disorder in patients with IBS. However, family psychiatric history in IBS patients who seek care has not been compared with family psychiatric history in persons with IBS who do not seek care.
Depression is common in the mothers of RAP children. In one study, mothers of RAP children had depression scores similiar to mothers of behavior-disordered children and significantly higher scores than mothers of healthy children.59 The scores of fathers were similar in the three groups. Two additional studies also found that mothers of RAP children were more depressed than mothers of healthy control subjects.42,47 In an epidemiologic survey, RAP children were significantly more likely than non-RAP children to have a maternal history of depression.66 Anxiety disorders are also common in the mothers of children with RAP,47,61,62,68 and generalized anxiety has been noted in 25%–28% of fathers.59,62 In one study, higher somatization scores in mothers and fathers were associated with higher somatization scores in RAP patients, but not in patients with abdominal pain due to organic causes or well children.65 In another study, 50% of RAP children had one or more first- or second-degree relatives who met criteria for somatization disorder.69 They also had one or more relatives with either alcoholism, antisocial, or disruptive behavior disorders. Therefore, a family history of psychiatric disorder is a risk factor for depression and anxiety in RAP. The relation of family psychiatric history to health care seeking has not been examined in RAP, although high levels of parental somatic complaints are associated with somatic complaints in RAP children.
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STRESS AND LIFE EVENTS
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IBS patients are particularly susceptible to the effects of stress. For example, anger increases symptoms in IBS,70 and stressful life events often precede flare-ups of symptoms or hospitalization.71,72 IBS patients report experiencing more negative life events than patients with peptic ulcer disease.73 However, in a prospective study of a clinical sample of IBS patients, daily stressors were neither strong nor consistent contributors to gastrointestinal symptoms.74 In contrast, a different prospective study using a within-subjects, lagged time-series design found that stress could predict symptoms in about two-thirds of subjects with IBS who were recruited from an IBS patient network.75 Moreover, an increase in severity of IBS symptoms was associated with an increase in perception of severity of stress in about one-third of subjects.
Loss and separation appear to be particularly prominent in the histories of IBS patients. One-third of 333 consecutive patients with IBS had lost a parent to death, divorce, or separation before age 15, and 61% of subjects reported unsatisfactory relations with their parents.76 In agreement with these findings, IBS patients were more likely than normal subjects to volunteer that they experienced losses and separations during childhood and in their adult families.25 A history of sexual or physical abuse was also significantly more common in adult females with functional gastrointestinal illness than in women with organic diagnoses,77 patients with nongastrointestinal disorders,78 or patients with IBD.79 Severity of abuse has been related to psychiatric symptomatology,79 and to severity of IBS symptoms.80 Finally, IBS patients also report they experienced fewer positive life experiences than IBS nonpatients or normal subjects.9
In one study of RAP, parents related the onset of gastrointestinal symptoms in their children to a stressful event in 67% of cases.27 The stresses included excitement, punishment, or familial disturbance, and in 23% of cases pain was related to a school activity. RAP patients themselves identify environmental stressors that worsen their abdominal pain,13 and symptom aggravation by stress was the same in children with RAP and in RAP children who also met criteria for IBS.13 In a prospective study, negative life events predicted higher levels of somatic complaints in RAP children, especially in RAP children scoring low in social competence.81 Having a father with high levels of somatic complaints predicted more somatic complaints at follow-up, regardless of negative life events. However, having a mother with high levels of somatic complaints predicted elevated somatic complaints in boys of families with high negative life events.
As in the case of IBS, loss and separation are also prominent in RAP children. The onset of abdominal pain in children with RAP is often related to a real or perceived traumatic event such as a loss or threat of loss.21 Overall, 55% of children with RAP report having experienced a recent death of a family member or close friend.21 In line with these results, increased parental absence has been noted among children with functional abdominal pain,82 and life events affecting interpersonal relationships in particular are related to abdominal pain.83 Furthermore, 25% of the parents of RAP children had lost a parent by death or divorce before they were 20 years of age, and 33% of these losses occurred during the parent's childhood.27 Mothers of hospitalized RAP children referred for psychiatric consultation were noted to be preoccupied with loss and death, as were the children themselves.84 In this study, 19 of 23 families experienced the loss or threatened loss of a grandparent during the child's hospitalization.
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DISCUSSION
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We reviewed clinical findings in IBS in adults and RAP in childhood to determine if what is known about each disorder can illuminate our understanding of the other, and to examine possible continuities between these two examples of adult and childhood functional bowel disorders. The evidence reveals striking similarities between the two disorders in the prevalence, course, medical and psychiatric comorbidity, family medical and psychiatric history, and patterns of association with life events. Continuity of the two disorders is also suggested by both follow-up and follow-back studies, which revealed that a subset of children with RAP have IBS when they reach early adulthood and that some IBS patients have childhood histories of abdominal pain.
Is RAP an early manifestation or a precursor of IBS? Many children with RAP meet criteria for IBS if sufficient symptoms are investigated, and in such cases, RAP may be a manifestation of IBS. In cases in which children with RAP do not meet criteria for IBS, RAP may be a precursor of IBS. Symptom-based diagnostic criteria for 25 adult functional bowel disorders have been proposed,1 and further studies are needed to characterize the functional bowel disorders of childhood to determine if a similar range of disorders occur in childhood. Outcome studies are also needed to identify factors determining the course and outcome of RAP and to determine the relationship of the childhood disorders to the various adult disorders. Further parallels between RAP and IBS are evident when the pattern of association of IBS and RAP with medical and psychiatric symptoms are considered. There is a strong overlap of IBS and fibromyalgia, and RAP patients show muscular tenderness that may be an early manifestation or precursor of fibromyalgia. Headaches and migraine are frequently noted in both disorders. Dysmenorrhea is also associated with IBS, and although dysmenorrhea has received little attention in RAP, probably because of the age of most subjects, there is evidence that some RAP children have dysmenorrhea by the time they reach adulthood. Recent theorizing suggests that the association of these disorders with IBS reflects central autonomic dysregulation and increased visceral nociception.85 The possibility that similar associations occur in RAP suggests that developmental factors may play an important role in the development of the comorbidity of IBS, migraine, fibromyalgia, and other disorders. Further exploration of the overlap of these disorders in children could do much to clarify the developmental origins of IBS.
Our review indicates that both IBS and RAP show elevated rates of psychopathology, particularily depression, anxiety, and somatic complaints. The association with psychiatric symptoms is strongest in persons with IBS who seek medical attention, but this aspect has not been fully explored in RAP. Panic disorder has been specifically linked to IBS, but to date a similar association has not been described in RAP. The precursors of later panic disorder, however, may be present in RAP, since childhood anxiety is linked to later anxiety disorders, including panic disorder, in adults. Somatization disorder also occurs in a subgroup of IBS patients, and multiple somatic complaints are often noted in children with RAP. However, the number and variety of complaints neccessary for the diagnosis of somatization disorder may be an artifact that precludes the diagnosis in pre- or early puberty. Therefore, high levels of somatic complaints in RAP may be early manifestations of somatization disorder.
Our review further shows that there are strong connections between life events and both IBS and RAP. Of particular interest are studies linking a history of loss and separation with IBS and RAP. This observation is important because loss and separation are associated with anxiety disorders and depression in childhood, and childhood losses and separation are linked to later depression and anxiety disorders, especially panic disorder, in adults.86 Of additional interest are the studies showing an association between IBS in adult women and a history of sexual or physical abuse. Childhood abuse could be an important etiologic factor for depression, anxiety, and somatic complaints in IBS.
Important similarities between IBS and RAP are also evident when the family medical and psychiatric history is examined. A family history of gastrointestinal problems is common in RAP families, and in persons with IBS, regardless of their patient status. There is limited information on whether the typical comorbid disorders are also present in families of IBS or RAP patients. In the case of IBS and RAP, a family history of gastrointestinal symptoms may be a risk factor conferring vulnerability for gastrointestinal symptoms. Such persons might have a biological vulnerability in the gastrointestinal system or in areas of the central nervous system that integrate signals from and coordinate the response to gastrointestinal symptoms. For example, the locus ceruleus has been implicated in IBS and anxiety disorders.50 An interesting question is whether a family history of functional bowel disorders or of the typical comorbid disorders (e.g., migraine, fibromyalgia) confers vulnerabilty for specific disorders, or confers a vulnerability common to the comorbid disorders. Since the typical comorbid disorders (e.g., fibromyalgia and migraine) are familial, it is plausible that any biological vulnerabilty is at the level of central processes common to the pathophysiology of these disorders. Thus, it would be of interest to know to what extent families of persons who have IBS and a comorbid disorder show the comorbid disorder. In this connection, it is interesting that RAP children have family histories of gastrointestinal problems and family histories of migraine.
The review further suggests that elevated rates of depression and anxiety are prominent in the families of IBS patients and in the parents of RAP patients. Vulnerability to psychological symptoms in RAP and IBS may be conferred by a family history of psychiatric disorder through genetic and/or environmental influences. Persons with a family history of both gastrointestinal disorder and psychiatric disorder may have vulnerabilities for both gastrointestinal symptoms (i.e., dysmotility and sensitivity to bowel distention) and negative affectivity that might then manifest as a disorder under the influence of life events or other adverse influences. This hypothesis would help explain why some, but not all, persons with IBS show high rates of psychological symptoms. A similar argument could be made in the case of RAP.
Further study of health care seeking in IBS and RAP is indicated. The evidence suggests that depression and anxiety and not severity of IBS symptoms drive health care-seeking behavior in IBS patients. Since the data suggest a family history of gastrointestinal problems is equally common in IBS patients and IBS nonpatients, a family history of gastrointestinal problems may not be a risk factor for health care seeking in persons with IBS. Family psychiatric history, however, may be a critical risk factor, since psychiatric symptoms lead to health care seeking in IBS patients. The further association of loss and separation with depression and anxiety in IBS suggests that an early history of loss and/or separation could be an important risk factor for later health care seeking, mediated by anxiety and depression. Similar observations could apply to childhood sexual abuse. Health care seeking in RAP clearly merits attention, since patterns of health care seeking may begin early. The determinants of health care seeking in RAP are likely to be different from those in IBS, as both parental and child behavior will influence health care seeking. Our review suggests that depression, anxiety, and gastrointestinal symptoms are prominent in parents of RAP children and the parents, as a result, may be prone to seek medical care. The anxious child, when stressed, may report somatic complaints or display illness behavior that increases parental anxiety and results in differential attention to the child's physical complaints.
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ACKNOWLEDGMENTS
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The authors thank Velma Dobson, Ph.D., and Holly Baird for their helpful comments.
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ABSTRACT
INTRODUCTION