Pathogenesis of psychogenic abdominal pain

The pathogenesis of abdominal pain of psychogenic origin is associated with the formation of a complex of pathological cerebroabdominal connections (direct and inverse). Affective disorders, most often of an anxious-depressive nature, of a neurotic nature due to their association with vegetative and endocrine, humoral reactions lead to a violation of vegetative-visceral (gastrointestinal) regulation, simultaneously reducing the thresholds of vegetative (visceral) intraceptive perception. This leads to an increase in anxiety, which further increases vegetative dysfunction. A number of factors, such as hyperventilation, increased neuromuscular excitability, increased motility of the gastrointestinal tract, disrupt the organization of perceptual activity (we have proven this by studying the dynamics of sensory and pain thresholds).

Abdominal pains, in the pathogenesis of which the leading role is played by mental factors and mechanisms (the first three forms), are the most difficult from the clinical diagnostic point of view. The close connection of abdominal pain phenomena with mental mechanisms requires, in addition to excluding organic disease of the abdominal organs, also the ability to conduct a clinical analysis using methods other than those in somatic medicine. Psychiatric and psychological qualifications are extremely necessary here. The experience of studying abdominal pains of this kind, as well as literature data, allow us to identify one fundamental criterion for clinical diagnostics, taking into account which allows a doctor with a psychosomatic orientation to determine the leading mechanisms of the pathogenesis of abdominal pain associated with the mental sphere within the framework of these abdominal pains. We are talking about the presence of a certain continuum of psychogenic-endocrine disorders within the framework of borderline neuropsychiatric disorders, the leading manifestation of which is a vivid phenomenon of abdominal pain. Clinical practice shows that in the complex mechanism of pathogenesis and symptom formation of abdominal algias, "pure" psychogenic and endogenous factors are rarely encountered. Nevertheless, it is necessary to identify the predominance of certain factors at the current level of our knowledge.

Mixed abdominal pain is pain in the pathogenesis of which psychogenic and endogenous mechanisms are combined. An important feature of such abdominal pain is the presence in the clinical picture of a number of characteristic moments that to a certain extent distinguish them from "pure" psychogenic pain. For example, in addition to the absence of a morphological substrate in the internal organs, a number of the identified criteria for positive diagnostics may be less distinct. Thus, the onset of the disease may be detected in connection with or simultaneously with pronounced disorders of the emotional sphere (most often depressive series), but without a clear connection with the events of the patient's life. In this case, one should try to clarify the "objective" events in the patient's life, to understand what the patient regards as life stress. It is necessary to clarify the patient's significant experiences and their connection with a specific situation.

Quite often, the term "pain" refers to various sensations, mainly of the synestopathic circle. Hypochondriacal and synestopathic fixation on the abdominal area, as a rule, does not exclude the presence of other sensations in other areas of the body. Hypochondriacal and depressive manifestations (there may be masked depressions) are most often encountered in these situations. It is important to note that among the manifestations of hidden depression, constipation is possible - a characteristic sign of gastrointestinal tract disorders.

Analysis of the course of abdominal pain in a number of cases reveals a clear tendency to a certain cyclicity (daily, seasonal). An important feature of this type of abdominal pain is considered to be a significantly lesser expression of vegetative disorders. The paroxysmal factor here is minimal, as a rule, we are talking about permanent pain manifestations, often persistent, monotonous, constant. The presence of the leading abdominal pain syndrome in the foreground in such patients often masks other psychopathological manifestations of an endoreactive nature underlying it, and even experienced psychiatrists in some cases, due to the presence of an impressive pain phenomenon, come to the erroneous conclusion about its somatic genesis.

The pathogenesis of these pains, in addition to the links reflected in the previous section, includes certain mechanisms that are less dependent on psychogenic effects and the associated vegetative-humoral consequences.

Abdominal pain as a manifestation of mental (endogenous) disease. The abdominal region ranks third in the population of psychiatric patients complaining of pain. There are various descriptions of the symptoms of such pain manifestations; they are designated as "abdominal psychalgias" and emphasize such features as the lack of connection between pain and the topography of organs; variability of localization, intensity, nature of pain, unusual descriptions of such pains ("biting", "stabbing", "burning", "twisting", etc.). They note a dissociation between the description of pain as "excessive", "unbearable" and a fairly satisfactory general condition of the patient, his mood, appetite, sleep, behavior; they also indicate other mental disorders. The presented characteristics allow us to suspect a mental (psychiatric) disease in patients, in which abdominal pain is only part of the clinical picture, requiring qualified psychiatric recognition.

When it comes to a psychiatric patient, one should not abandon further searches for organic causes of pain. After all, a somatic cause, likely to be encountered in the population, may also be present in a patient with psychiatric pathology. In this context, it is important to designate a special form of pathology, when all the patient's aspirations and efforts are directed at searching for non-existent, mythical somatic causes (Munchausen syndrome). The most surprising thing here is the fact that repeated fruitless surgical interventions do not stop patients in their search. As a rule, such patients always find "their" doctors, who are ready to perform repeated operations.

The pathogenesis of the disease in this case, as can be seen from the above, is connected, in essence, not with the phenomenon of pain, but with the process of mental illness, when “pain in the abdomen” is a kind of overvalued, delusional idea that organizes the pathological behavior of the patient.

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