Psychogenic abdominal pain - Diagnosis

The most important issue in the section on psychogenic abdominalgia is the issue of criteria for diagnosing abdominal pain. It is important to note that one negative diagnosis (exclusion of organic disease of the internal organs) is insufficient: it is necessary to identify positive criteria for diagnosis. Based on published works devoted to this issue in psychogenic abdominal pain, taking into account the existence of criteria for diagnosing neuroses, as well as an analysis of the results of a study of patients with abdominal pain, we have identified the leading and secondary criteria for diagnosing psychogenic abdominal pain.

The leading criteria for diagnosing abdominal pain:

1. the presence of abdominal pain without organic changes in the internal organs or in the presence of certain changes that cannot explain the severity of the pain (algic-organic dissociation);
2. the connection and involvement of mental factors in the phenomenon of pain:
   • the presence of a certain temporal connection between objective stressful events in the patient’s life, the onset and course (intensification, exacerbation, decrease, disappearance, change) of abdominal pain;
   • the presence of a certain connection between the dynamics of the psychogenic situation, the subjective experiences of the patient and the course of abdominal pain;
   • the presence of factors that could explain the localization of pain (the presence of a history of abdominal pain in the patient’s environment - a symptom model), pathological (illness, injury) and physiological (pregnancy) conditions, the presence in the structure of psychogenic situations that would contribute to the pathological fixation of attention to the abdominal area, etc.;
3. Abdominal pain is not a sign of mental (psychiatric) illness.

Additional criteria for diagnosing abdominal pain:

1. unusual clinical manifestations and course of abdominal pain and their dissimilarity to known somatic suffering;
2. change in the patient’s behavior (obtaining secondary privileges from the presence of pain: disability group, regulation of family relationships, the ability to avoid unpleasant situations and activities, etc.);
3. the presence of other pain manifestations in various areas of the body and the projection zone of internal organs, diffuse pain manifestations (“painful personality”, pain-prone);
4. the presence of psychopathological disorders in the patient;
5. dissociation between the severity of pain and the patient's behavior;
6. a certain effect from psychotherapy and the use of psychotropic drugs;
7. the presence of a pronounced psychovegetative syndrome and a tendency to paroxysmal course.

Several aspects concerning the proposed criteria need to be highlighted.

It may be difficult to assess the genesis of abdominal pain in the presence of certain changes in the internal organs, if these changes are not the basis of the pathogenesis of pain, but serve only as a background. Long-term observation of the patient and constant comparison of the dynamics of the clinical picture and the dynamics of the "minimal organic process" allow us to confidently identify its "background" role.

A close connection between the dynamics of a number of parameters of the mental sphere, events in the patient's life with the debut, the dynamics of the course and manifestation of the clinical picture of abdominal pain is a strong argument in favor of the diagnosis of abdominal pain of psychogenic origin. Patients, as a rule, for a long period (months, years) were aimed at finding an organic substrate of their disease, and the possibility of pain due to sociopsychological factors most often seems unlikely to them. Moreover, the opinion that stress and experiences can reveal and exacerbate the presence of somatic suffering in the patient is quite real and logical. Therefore, a doctor searching for possible psychogenic causes of the disease is required to have a certain degree of skill, flexibility, knowledge of the technique of conducting this type of analysis. The main thing is that after a detailed identification of the clinical symptoms of the disease, it is also necessary to unobtrusively but purposefully clarify the patient's idea of u200bu200bhis suffering (internal picture of the disease). Subsequently, it is necessary to clarify the anamnesis of life and experienced stresses, life events and establish the factors fundamental for proving the psychogenic nature of the disease, reflected in the criteria proposed above. The additional criteria identified are most often easier to identify, since they do not require a targeted psychological analysis, unlike the criteria for positive diagnostics (leading criteria, points 2, a, b, c). Often, the signs reflected in the additional criteria are sufficient to substantiate the psychogenic nature of abdominal pain, but the possibility of error is significantly greater than when using the leading criteria.

A characteristic feature of psychogenic abdominal pain is the presence of concomitant polysystemic vegetative manifestations. In this case, the patterns of the course of abdominal pain are largely determined, in addition to the above-mentioned factors of psychogenesis, also by a tendency to paroxysmal course. As a rule, abdominal pain in these patients is of a permanent paroxysmal nature. Examination of patients allowed us to establish manifestations of hyperventilation and tetanic nature in their syndromic "environment".

Thus, the presence of a pronounced psychovegetative syndrome in these patients is one of the features of their clinical manifestation, and the tendency to paroxysms is a reflection of the specificity of their course.

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