Paediatric Gastrointestinal Disorders

A Psychosocial Perspective

Clarissa Martin

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9781909368361
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina pediátrica

The medical specialty of paediatric gastroenterology is focused on problems and disorders within the gastrointestinal tract, liver and pancreas of children from infancy until age eighteen. This inspirational compilation provides information on current research and clinical practice regarding the psychosocial aspects of paediatric gastrointestinal c

Foreword

You cannot reason with a hungry belly … it has no ears.

—Greek Proverb, BCE

Man should strive to have his intestines relaxed all the days of his life.

—Moses Maimonades (Rambam), 13th Century

Affectes and passions of the minde … annoye the body, and shorten the lyfe.

—Sir Thomas Elyot, 16th Century

A good set of bowels is worth more to a man than any quantity of brains.

—Josh Billings (Henry Wheeler Shaw), 19th Century

The development of the Biopsychosocial medical model is posed as a challenge for both medicine and psychiatry. For despite the enormous gains which have accrued from biomedical research, there is a growing uneasiness among the public as well as among physicians and especially among the younger generation that health needs are not being met.…

—George L. Engel MD, 20th Century (1977)

Throughout recorded history poets, historians and physicians have recognized the close linkage between mind and gut, and why not? From the time of conception, the neural plate of the embryo serves as the anlage from which the central nervous system, spinal cord and myenteric plexi grow and differentiate, and so this linkage is hardwired and forever connected. Thus it comes as no surprise to this readership that understanding the reciprocal relationship between psychosocial and gastrointestinal functioning in health and disease is critical to understanding and caring for our patients, young and old. But why, less than 40 years ago, would George Engel the physician icon of the Biopsychosocial model write about this with such somber tones in his seminal paper? (Engel, 1977).

Answering this question requires a historical perspective on how the relationship of mind and body have been viewed over time (Drossman, 1998). Throughout most of Western history, beginning with the ancient Greeks there has existed the concept that mind and body were inseparable, and medical disease must take into account the entire person rather than just the diseased part. However, this changed, beginning in 1637, when Rene Descartes proposed that there is a separation of the thinking mind (res cogitans) from the body (res extensa). As he quotes: ‘On the one hand I have a clear and distinct idea of myself, in so far as I am a thinking, non-extended thing; and on the other hand I have a distinct idea of body, in so far as this is simply an extended, non-thinking thing. And, accordingly, it is certain that I am really distinct from my body, and exist without it.’ (Drossman, 2006). This dualistic concept of separation of mind and body powerfully influenced scientific thinking and the practice of medicine. Notably the dissection of human cadavers, previously prohibited (because the spirit was thought to reside there), was now permitted, so what was seen (i.e. structural disease) was real and amenable to scientific study. In contrast symptoms, behaviors and illness without pathology was dismissed as insanity or at the time, possession by evil. These patients were ignored and/or relegated to the asylums. Over time this dualistic thinking morphed into the modern medical concept of continually seeking an ‘organic’ cause in an effort to frame the patient’s reports of illness into something observable and real. When no cause is found, it is considered as ‘functional’ (not understood, a second class disease) and without reason presumed psychiatric.

Over the last three centuries the dualistic concept has permeated all sectors of society and it has relegated to second class the value of the teaching, learning and investigation of non-pathologically based disorders, in particular the functional somatic and GI diagnoses, and patients who have these disorders can be given negative attributions and labelled as being ‘psychosomatic’.

Close to biomedical dualism is reductionism, i.e. the relegation of diseases to single causes that are both necessary and sufficient to explain the illness (also called linear causality). This is represented by Koch’s ‘germ theory’ and has been important in understanding acute infectious disease. However, single-cause etiology has its limitations with chronic disease which is complex and multi-causal. Several years ago a notable gastroenterologist said at a symposium on IBS: ‘Psychological issues are important, but finding the etiology (of IBS) will take care of the problem.’ This person acknowledged the importance of psychological factors, but his conceptualization was both reductionistic and dualistic.

Beginning in the late 1970s, educators were reporting that patients with structural diseases (e.g. inflammatory bowel disease, ulcer disease) varied in the illness experience from asymptomatic to severe given the same disease activity, and psychiatric and gastrointestinal disorders considered as functional now were found to have genetic determinants and biochemical and immunological correlates. Thus organic disease was being functionalized and functional disorders organified (Drossman, 2006). Then in 1977, Engel, being dissatisfied with the existing dualistic thinking of the time, proposed a multi-causal model that integrates mind and body: where biologic, psychological and social subsystems interact at multiple levels. This Biopsychosocial model reconciled the emerging research findings not explained by biomedicine, permitted the heterogeneity of medical illness and the various physiological components and clinical expressions of disease, and also opened the door to the concept of mind–body (e.g. brain–gut) disorders.

I believe the field of gastroenterology may be ahead of the curve in moving forward with these newer concepts; the organic and functional dichotomy within GI is disappearing through good research in neurogastroenterology and education (Drossman, 2006; Drossman 2005). I also believe that the Rome Criteria laid the foundation for upgrading our knowledge in the field by classifying functional GI disorders (Drossman et al., 2006). This makes them identifiable and thus amenable to research which leads to more targeted treatments based on the diagnosis for clinical practice. Through this the disorders are also legitimized as ‘real’ entities. The Rome Foundation is proud to have recruited superb pediatric investigators and clinicians who have defined, classified and made recommendations for the care of patients with pediatric functional GI disorders.

Thus the Biopsychosocial model and the Pediatric Rome Criteria provide a template to aid in the elaboration of the science and art of pediatric gastrointestinal disorders; that work is well represented in this informative book by Drs Martin and Dovey. The editors who singularly have promoted this model for years have also joined to produce this book. Paediatric Gastrointestinal Disorders: a psychosocial perspective forges the way for a greater integration of knowledge in the field by bringing together a multidisciplinary team of pediatric GI clinicians, behaviorists, nutritionists and investigators to help educate clinicians on understanding and caring for the ‘whole child’.

Their aim ‘… to offer health professionals, students and health professionals in training, and members of the public a multidisciplinary perspective on the psychosocial considerations of children and young people with gastrointestinal disorders and their families’ is well handled in this book. Chapters initially address the definitional and classification aspects of FGIDs, models of care, specific psychological treatments such as CBT, social and family influences on the child, and nutritional aspects of care including home parenteral nutrition. Following this they provide information on the clinical aspects of care: autism spectrum, tube feeding, rumination syndrome, inflammatory bowel disorders, defecation disorders, as well as information on working with adolescents. The book ends with a section on various assessment measures and other practical material that might be of help in clinical practice.

I am most pleased to have been asked to contribute to this book and am hopeful that many others will benefit from this well written compendium of knowledge in the management of patients with pediatric GI disorders.

Douglas A. Drossman, MD

Professor Em eritus of Medicine and Psychiatry,

University of North Carolina

President, The Rome Foundation

President, Center for Education and Practice of

Biopsychosocial Care

Drossman Gastroenterology, PLLC

Chapel Hill, North Carolina, USA

March 2014

References

Drossman DA. Presidential address: gastrointestinal illness and biopsychosocial model. Psychosom Med. 1998; 60(3): 258–67.

Drossman DA. Functional GI disorders: what’s in a name? Gastroenterol. 2005: 128(7): 1771–2.

Drossman DA. Functional versus organic: an inappropriate dichotomy for clinical care....