Psychogenic abdominal pain: diagnosis

The most important issue in the section on psychogenic abdominal disorders is the question of criteria for the diagnosis of abdominal pain. It is important to note that one negative diagnosis (exclusion of organic disease from the internal organs) is not enough: it requires the allocation of positive diagnostic criteria. Based on the published works devoted to this issue with psychogenic pains in the abdomen, taking into account the existence of criteria for diagnosing neuroses, as well as analyzing the results of the study of patients with abdominal pain, we have identified leading and secondary criteria for the diagnosis of psychogenic abdominal pain.

Leading criteria for the diagnosis of abdominal pain:

1. the presence of pain in the abdomen without organic changes from the internal organs or in the presence of certain changes that are not able to explain the severity of pain (algic-organic dissociation);
2. communication and the involvement of mental factors in the phenomenon of pain:
   • presence of a certain temporary connection between objective stressful events in the patient's life, debut and course (intensification, exacerbation, decrease, disappearance, change) of abdominal pain;
   • presence of a certain connection between the dynamics of the psychogenic situation, the subjective experiences of the patient and the course of abdominal pain;
   • presence of factors that could explain the localization of pain (the presence of a symptom in the patient's anamnesis in the environment), pathological (disease, trauma) and physiological (pregnancy) conditions, the presence of psychogenic situations in the structure that would contribute to pathological fixation of attention to abdominal zone, etc .;
3. pain in the abdomen is not a sign of mental (psychiatric) disease.

Additional criteria for the diagnosis of abdominal pain :

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

It is necessary to single out several aspects concerning the proposed criteria.

Uneasy can be an evaluation of 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 identify with certainty its "background" role.

The close connection between the dynamics of a number of parameters of the psychic sphere, events in the life of a patient with a debut, the dynamics of the course and the manifestation of the clinical picture of abdominal pain is a strong argument in favor of the diagnosis of abdominal pains of a psychogenic nature. Patients, as a rule, for a long period (months, years) were aimed at finding the organic substrate of their disease, and the possibility of the appearance of pain due to socio-psychological factors is most likely unlikely. Moreover, the opinion that stresses, experiences can reveal and exacerbate the patient's somatic suffering is quite real and logical. Therefore, from a doctor who is searching for possible psychogenic causes of the disease, a certain degree of skill, flexibility, and knowledge of the technique of carrying out this type of analysis are required to some extent. The main thing is that after detailed detection of clinical symptoms of the disease, it is also necessary to unobtrusively but purposefully clarify the patient's presentation of his suffering (internal picture of the disease). In the subsequent it is necessary to find out the anamnesis of life and the experienced stresses, life events and establish the factors that are important for the proof of the psychogenic nature of the disease, reflected in the criteria proposed above. The allocated additional criteria are most often revealed more easily, since they do not require targeted psychological analysis, in contrast to the criteria for positive diagnosis (leading criteria, points 2, a, b, c). Often, the symptoms reflected in additional criteria are sufficient to justify the psychogenic nature of abdominal pain, but the possibility of error is much greater than when applying the leading criteria.

A characteristic feature of pain in the abdomen of psychogenic nature is the presence of accompanying polysystemic vegetative manifestations. In this case, the regularities of the course of abdominal pain are largely determined, in addition to the psychogenic factors mentioned above, also a tendency to paroxysmal flow. As a rule, abdominal pain in these patients is permanently paroxysmal. The examination of patients made it possible to establish in their syndromal "environment" manifestations of hyperventilation and tetanic nature.

Thus, the presence of a bright psycho-vegetative syndrome in these patients is one of the features of their clinical manifestation, and the propensity to paroxysms is a reflection of the specificity of their course.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]