Psychogenic pain in the abdomen

Psychogenic disorders of the digestive system, including abdominal pain, are often found in both the population and among patients seeking medical care.

In the population, functional disorders of the gastrointestinal tract in the form of indistinct or episodic dyspepsia, according to D. Morgan (1973), occur in 30% of people. Such phenomena are especially frequent in children. Complaints of abdominal pain in a child's random population were met in 11-15% [Aplay J., 1975]. In the studies of W. Thomson, K. Nea-ton (1981) 20% of the adult population surveyed complained of abdominal pain (more than 6 times during the year).

Acute abdominal pain, as is known, is a dramatic situation, requiring urgent, more often surgical, evaluation and treatment. Quite often, abdominal pain of an acute nature is a sign of inorganic (psychogenic, functional) disorders of the gastrointestinal tract. This is evidenced by the fact that in 10-30% of patients operated on for acute appendicitis, in a remote the vermiform appendage during histological examination does not find any changes; most often such patients are young women.

Special studies of patients with abdominal pain, operated in the presence of a healthy process, revealed frequent violations on the part of the psychic sphere (primarily depressive manifestations) and a large number of stressful life events.

In the structure of the incidence of digestive organs, the functional (psychogenic) genesis of disorders of the gastrointestinal tract takes a large proportion. According to W. Dolle (1976), disorders of the gastrointestinal tract of psychogenic nature are detected in 30-60% of patients with diseases of the digestive system. Among patients suffering from various diseases of the gastrointestinal tract with the presence of depressive disorders, 64% could not find an organic substrate, with abdominal pain and irritable bowel syndrome.

Pain in the abdomen, which has no fundamentally organic changes and is recurrent, was found in 90-95% of sick children with disorders of the gastrointestinal tract. Among patients with psychogenic disorders of the gastrointestinal tract, abdominal pain as a leading manifestation occurs in 30% of patients. The psychogenic character of chronic pain was determined in 40% of patients with abdominal pain.

Pain in the abdomen of a psychogenic nature

This article deals with abdominal pain (abdominal pains) that are not associated with organic diseases of the gastrointestinal tract and gynecological area and which present a great diagnostic difficulty in practical medicine. Immediately it should be emphasized that the abdominal pain, which will be discussed, have, as a rule, a polyfactorial etiology and pathogenesis; the main links here are psychogenic, neurogenic, endocrine, metabolic and other mechanisms or their combinations.

Often in the literature such pains are denoted by the general term "inorganic", which emphasizes the absence of traditional for organic disease of the gastrointestinal tract or gynecological sphere of the morphological changes underlying the disease. As a rule, doctors come to such conclusions after clinical analysis and application of modern methods of examination of the abdominal cavity organs (endoscopy, most often panendoscopy, radiographic and radiographic, ultrasound, computer tomography), and after diagnostic laparoscopy and biopsy of various organs.

The use of these modern, sufficiently reliable methods of research has influenced the further development of the doctrine of inorganic pain of the abdominal region.

Nevertheless, the diagnosis of abdominal pains of inorganic nature is a difficult question, almost always a test for a doctor who must solve a real riddle - an equation with many unknowns. Usually the doctor stops on this or that diagnosis depending on personal inclination, own experience or clinical "inspiration".

Given the complexity of the diagnosis of inorganic abdominal pain, the high possibility of diagnostic errors, the evaluation of abdominal pain as unrelated to diseases of the abdominal organs in the past was rare; perhaps this was fully justified. At this stage, clinical approaches to assessing abdominal pain should be more active. The following circumstances indicate this possibility:

1. Studies of the phenomenon of pain in recent years have shown that the sensation of pain is extremely complex and multilevel in the mechanisms of psychogenesis by the phenomenon. The pain, having a certain localization within the framework of an organ or system, is simultaneously "superficial" in nature, which is most clearly manifested in chronic pain.
2. In recent years, it has become increasingly clear that the positive diagnosis in determining a particular nature of the disease is absolutely necessary. For diagnosis, for example, psychogenic disease, in addition to reliable exclusion of the organic basis of the disease, requires the existence of facts that prove the psychogenic genesis of this suffering.
3. Progress in the study of the psychosomatic foundations of many diseases not only opens great prospects in understanding the need for a unified view of the phenomenon of man and the study of his illnesses, but also allows the formation of a certain conceptual apparatus in practical doctors. Orientation only for the search and finding the material substrate of the disease without taking into account the psychosomatic unity of a particular patient narrows the diagnostic approach of the doctor, not allowing him to understand and see possible ways of therapy. Most often, such situations occur in doctors of surgical specialties.

The lack of experience and opportunities for a subtle, non-standard and non-standard analysis in the search for causal relationships between the pain and pathology of an organ, especially when it reveals a mild disorder, leads to the fact that many patients with abdominal pain " in the victims of surgical redundancy "[strongorten-strongrivine J., 1986].

Classification of abdominal pain from the position of a neurologist

Trying to systematize the existing options for abdominal pain, it is necessary to identify those aspects that fall within the competence of the neurologist. Psycho-vegetative, neurological mechanisms play a different role in the pathogenesis of this or that variant of abdominal pain. Nevertheless, the neurological view of this problem is becoming more and more necessary, taking into account the achievements of both practical and theoretical neurology. Of course, between the classes of psychogenic pain in the abdomen and the pain associated with organic diseases of the gastrointestinal tract, lies a whole group of abdominal pains, in which neither psychogenic nor organic factors are obvious causes of the pain. The proposed classification is based on the pathogenetic principle of psychosomatic unity in the broad sense of the word. At the center of the analysis is the phenomenon of abdominal pain, and the analysis is conducted from the position of a broad neurological approach, taking into account the modern classification of vegetative disorders.

1. Abdominal pain associated with cerebral (supra-segmental) autonomic disorders
   • Pain in the abdomen of a psychogenic nature
   • Pain in the abdomen of mixed (psychogenic with endogenous inclusions) character
   • Pain in the abdomen as manifestations of mental (endogenous) disease
   • Abdominal migraine
   • Epilepsy with abdominal seizures
   • Abdominal form of spasmophilia (tetany)
   • Abdominal pain in patients with hyperventilation syndrome
   • Periodic illness
2. Abdominal pain associated with peripheral (segmental) autonomic disorders
   • The defeat of the solar plexus
   • Gastric tabular crises
   • Porphyria
   • Pain in abdomen of vertebrogenic nature
   • Multiple sclerosis
   • Syringomyelia
   • Tumors of the brain and spinal cord
3. Pain in the abdomen with diseases of the gastrointestinal tract of unclear etiology.
   • Irritable bowel syndrome.
   • Dyspepsia.

The pathogenesis of abdominal pains of a psychogenic nature is associated with the formation of a complex complex of pathological cerebro-abdominal connections (direct and reverse). Affective disorders most often of an anxiety-depressive nature, neurotic nature due to their conjugation with vegetative and endocrine, humoral reactions lead to a violation of vegetative-visceral (gastrointestinal) regulation, while reducing the thresholds of vegetative (visceral) intracep- tive perception. This leads to an increase in anxiety, which further increases autonomic dysfunction. A number of factors, such as hyperventilation, increased neuromuscular excitability, increased motility of the gastrointestinal tract, disrupts the organization of perceptual activity (this was proved by studying the dynamics of sensory and pain thresholds).

Pathogenesis of psychogenic pain in the abdomen

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.

Psychogenic pain in the abdomen - Diagnosis

Pain in the abdomen with abdominal migraine is most common in children and young men, but it is also often found in adult patients. As abdominal equivalent of migraine, abdominal pain can be accompanied by vomiting and diarrhea. Vomiting, as a rule, is persistent, imperative, with bile, not bringing relief; pain expressed, diffuse, can be localized in the navel, accompanied by nausea, vomiting, blanching, cold extremities. Vegetative concomitant clinical manifestations can be of varying degrees, sometimes their vivid manifestation forms a sufficiently distinct picture of one or another variant of the vegetative crisis. The duration of abdominal pain in these situations varies - from half an hour to several hours or even a few days. The duration of vegetative accompanying manifestations can also be different. It is important to emphasize that the presence of hyperventilation components in the structure of vegetative manifestations can lead to the manifestation and intensification of such tetanic symptoms as numbness, stiffness, muscle information and spasms in the distal extremities (carpal, carpopedic spasms).

Psychogenic pain in the abdomen - Causes and symptoms

[1], [2], [3], [4], [5], [6], [7], [8]