The potential role of behavioral therapies in the management of centrally mediated abdominal pain

Background Chronic abdominal pain carries a substantial health care burden but little is known about best practices for it management across ambulatory, hospital, and emergency room settings. This is especially true when abdominal pain presents in the absence of peripheral triggers like tissue injury (e.g. appendicitis) or altered bowel movements (e.g. IBS). Unfortunately, once central sensitization has occurred, pain can present wiithout any stimulation or with minimal peripheral stimulation (feeling of clothing on the area) to the abdominal region. Several studies have proven the superior efficacy of behavioral interventions on many centrally mediated pain conditions including headaches and musculoskeletal problems. However, behavioral treatment of centrally mediated abdominal pain is less investigated due to the complexity of the patients involved and the poor understanding of the factors which either initiate or maintain persistent GI pain. Purpose We examine the evidence for a range of psychological and behavioral interventions in the context of centrally mediated abdominal pain. In addition to a strong rationale for a behavioral approach tied to the fear avoidance model of pain, we describe the structure, therapeutic targets, current evidence and relevance for each class of behavioral interventions. The fear avoidance model of pain is the preferred construct in examination of centrally‐mediated abdominal pain conditions. The pain experience is divided between a sensory‐discriminative (or the sensation of pain) and motivational‐affective component (the perception of pain). Fear is a natural consequence of the motivational‐affective dimension, but the way fear is managed will drive prognostic outcomes. Patients who confront their pain with the assistance of therapies will likely recover, while those who avoid the fear experience will exacerbate the disease process through maladaptive behaviors.