Chronic Pain Edition The Relationship between Adolescent Chronic Pain & Stress

Adolescent Somatization: What it is and why it matters

One thing COVID has undeniably brought to light is the youth mental health crisis. Reports show dramatic increases in the rates of teen anxiety, depression and suicidal ideation (Panchal et al., 2021). While understanding the role of stressors on youth mental health is vital, what’s equally as important is discussing how adolescent stress impacts physical health, namely chronic pain and somatization.

Somatization is a medical term used to describe symptoms such as pain, headache, and stomachache that are not explained by a physical condition. For example, a teen may be experiencing frequent upset stomach but clinician examinations report no evidence of Irritable Bowel Syndrome (IBS) or Inflammatory Bowel Disease (IBD). Even without evidence of organic disease, it’s important to acknowledge these symptoms because they can cause chronic pain and functional disability.

It’s estimated that between 10% and 30% of adolescents experience some form of somatization (Geist, Weinstein, Walker, & Campo, 2008; Mayou & Farmer, 2002). De-identified data from Neolth, a digital health app for teens, further validates these estimates. In a random sample of 850 teens who started the Neolth program during 2022, 31.3% (N=266) reported experiencing headaches, 21.2% (N=180) upset stomach, and 10.7% (N=91) chronic pain. Yet only 6.8% (N=58) reported being diagnosed with a condition responsible for their symptoms. If there is no evidence of organic disease, what might be attributable to their pain symptoms? The answer is stress.

Stress & Pain Physiology in Adolescence

The physiology behind the stress-pain connection may not be common knowledge, but it is well-studied. When teens experience stressors – whether it be school exams, romantic relationships, or social media pressure – a hormonal cascade occurs in the body. The hypothalamic-pituitary-adrenal (HPA) Axis is activated, leading to an increase in circulating stress hormones like cortisol. These stress hormones, when elevated for extended periods, have negative effects on physical health: increased inflammation throughout the body; dysregulation of the gastrointestinal (GI) system, bloating, irregular bowel movements, and increased pain – to name a few. So it’s not just mental health that’s impacted by stress, but teens’ physical health as well.

One type of stressor frequently experienced by adolescents is Adverse Childhood Experiences (ACES), which include violence in the home, substance use in the home, divorce of parents, and other serious stressors. ACES are a powerful risk factor for chronic pain in teens. In a study of almost 50,000 U.S. adolescents, it was found that 49.8% had at least one ACE in their lifetime, and those with one or more ACE had almost twice the risk of chronic pain compared to those with no ACES (Groenewald et al., 2020a).

Why does this matter? We typecast chronic pain as a disease associated with aging. However, since teens experience higher levels of stress compared to older generations, they are at risk for developing chronic pain (APA, 2018). Studies found the global prevalence of chronic pain among adolescents as high as 20.6% (Mills et al., 2019). In taking a holistic view, one can see that a cycle exists between teen’s emotional and physical health: those with untreated stress may develop painful somatic symptoms, which further elevates stress and can lead to continued and increased physical pain.

Tactical Steps to Address Adolescent Stress and Pain

So how do we break this stress-pain cycle? Awareness is the first step. By monitoring symptoms – not just stress in isolation but its association to mental and physical health symptoms – we can see patterns emerge. Teens who use a symptom tracking app, for example, can learn to connect their pain symptoms with periods of elevated stress. They might observe that pain symptoms peak on the day of or after high emotional stress.

Once awareness is built, teens can get proactive about keeping stress low. Stress management – whether learned and practiced at school, home or elsewhere – is a science based way to reduce the damage wrought by chronic stress. Teens can use guided relaxation exercises to keep stress low, as well as manage acute stress during periods of overwhelm. Children and adolescents in particular appear to benefit from these interventions at school and in their personal lives (Whiting et al, 2021). In as little as three weeks, adolescents who practice stress management saw a reduction in chronic pain (Shaygan & Jaberi, 2021).

After experiencing an initial reduction in pain symptoms, maintenance is key to prevent symptom recurrence. This means teens should practice stress management not only during times of high stress or pain flares, but also during times of good health. This may look like engaging in guided stress management practices 2-3 times per week, for 5-20 minutes. It may also include activities such as exercise, whether gentle or vigorous, getting 8 or more hours of sleep each night, and even spending time with friends and family. Whatever activity is chosen, teens should consider scheduling stress management into their calendar as a way to encourage consistent engagement.

Takeaways

Immune, nervous, and stress response systems work synergistically to produce sickness behavior. In some teens, high stress manifests as depression, apathy, as well as difficulties with learning and memory. For others, high stress manifests as chronic pain or somatization (Alsaggaf & Coyne, 2020; Groenewald et al., 2020b; Geist, Weinstein, Walker, & Campo, 2008; Mayou & Farmer, 2002).

The connection between chronic stress and chronic pain in children and adolescents is so strong that there is now a call for making stress assessment part of routine medical care for pediatric patients (Nelson et al., 2020). Such assessments would help clinicians and parents identify adolescents at risk for somatization. Once risk is identified, the adolescent should be encouraged to build awareness of the stress-pain connection through symptom tracking as well as establish a stress management routine for symptom reduction.

References

1. Panchal, U., Salazar de Pablo, G., Franco, M., Moreno, C., Parellada, M., Arango, C., & Fusar-Poli, P. (2021). The impact of COVID-19 lockdown on child and adolescent mental health: systematic review. European child & adolescent psychiatry, 1-27.
2. Geist, R., Weinstein, M., Walker, L., & Campo, J.V. (2008). Medically unexplained symptoms in young people: The doctor’s dilemma. Paediatrics & Child Health, 13(6):487–491.
3. Mayou, R., & Farmer, A. (2002). ABC of psychological medicine: Functional somatic symptoms and syndromes. BMJ: British Medical Journal, 325(7358):265.
4. Groenewald, C. B., Murray, C. B., & Palermo, T. M. (2020a). Adverse childhood experiences and chronic pain among children and adolescents in the United States. Pain Reports, 5(5).
5. American Psychological Association (2018). Stress in America: Generation Z. Stress in America™ Survey.
6. Mills, S. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: a review of its epidemiology and associated factors in population-based studies. British Journal of Anaesthesia, 123(2), e273-e283.
7. Whiting, S. B., Wass, S. V., Green, S., & Thomas, M. S. (2021). Stress and learning in pupils: Neuroscience evidence and its relevance for teachers. Mind, Brain, and Education, 15(2), 177-188.
8. Shaygan, M., Jaberi, A. The effect of a smartphone-based pain management application on pain intensity and quality of life in adolescents with chronic pain. Sci Rep 11, 6588 (2021). https://doi.org/10.1038/s41598-021-86156-8
9. Alsaggaf, F., & Coyne, I. (2020). A systematic review of the impact of chronic pain on adolescents’ school functioning and school personnel responses to managing pain in the schools. Journal of Advanced Nursing, 76(8), 2005-2022.
10. Groenewald, C. B., Tham, S. W., & Palermo, T. M. (2020b). Impaired school functioning in children with chronic pain: A national perspective. The Clinical Journal of Pain, 36(9), 693.
11. Nelson, S., Burns, M., & Logan, D. (2021). The clinical utility of a brief psychological stress measure (patient-reported outcomes measurement information system) in youth with chronic pain. Pain Medicine, 22(1), 91-99.