Psychogenic abdominal pain

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

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

Acute abdominal pain is known to be a dramatic situation requiring urgent, most often surgical, assessment and treatment. Quite often, acute abdominal pain is a sign of non-organic (psychogenic, functional) gastrointestinal disorders. This is evidenced by the fact that 10-30% of patients operated on for acute appendicitis have a remoteHistological examination of the appendix does not reveal any changes; most often, such patients are young women.

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

In the structure of gastrointestinal tract morbidity, the functional (psychogenic) genesis of gastrointestinal disorders occupies a large proportion. According to W. Dolle (1976), gastrointestinal disorders of psychogenic origin are detected in 30-60% of patients with digestive system diseases. Among patients suffering from various gastrointestinal diseases with depressive disorders, in 64% it was not possible to find an organic substrate, while abdominal pain and irritable bowel syndrome were detected.

Abdominal pain, which is not based on organic changes and is recurrent, was found in 90-95% of sick children with gastrointestinal disorders. Among patients with psychogenic gastrointestinal disorders, abdominal pain as the leading manifestation is found in 30% of patients. The psychogenic nature of chronic pain was determined in 40% of patients with abdominalgia.

Abdominal pain of psychogenic nature

This article will discuss abdominal pain (abdominalgia) that is not associated with organic diseases of the gastrointestinal tract and gynecological sphere and that present a great diagnostic difficulty in practical medicine. It should be immediately emphasized that the abdominal pains that will be discussed usually have 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 designated by the general term "non-organic", which emphasizes the absence of traditional for organic diseases of the gastrointestinal tract or gynecological sphere morphological changes underlying the disease. As a rule, doctors come to such conclusions after clinical analysis and the use of modern methods of examining abdominal organs (endoscopy, most often panendoscopy, radiographic and X-ray, ultrasound, computed tomography studies), as well as after diagnostic laparoscopy and biopsy of various organs.

The use of these modern, fairly reliable research methods influenced the further development of the theory of non-organic abdominal pain.

However, the diagnosis of non-organic abdominal pain is a difficult question, almost always a touchstone for the physician, who must solve a real riddle - an equation with many unknowns. Usually the physician settles on one or another diagnosis depending on personal inclination, his own experience or clinical "inspiration".

Given the difficulty of diagnosing non-organic abdominal pain and the high potential for diagnostic errors, the assessment of abdominal pain as unrelated to abdominal diseases has rarely been done in the past; perhaps this was entirely justified. At this stage, clinical approaches to the assessment of abdominal pain should be more active. The following circumstances indicate this possibility:

1. Research into the phenomenon of pain in recent years has shown that the sensation of pain is an extremely complex and multi-level phenomenon in terms of psychogenesis mechanisms. Pain, having a certain localization within an organ or system, simultaneously has a “supra-organ” character, which is most clearly manifested in chronic pain.
2. In recent years, it has become increasingly clear that positive diagnostics in determining the nature of a disease is absolutely necessary. For the diagnosis of, for example, a psychogenic disease, in addition to the reliable exclusion of the organic basis of the disease, the presence of facts proving the psychogenic genesis of this suffering is required.
3. Progress in the study of the psychosomatic foundations of many diseases not only opens up great prospects in understanding the need for a unified view of the phenomenon of man and the study of his diseases, but also allows for the formation of a certain conceptual apparatus in practicing doctors. Focusing only on the search and finding of the material substrate of the disease without taking into account the psychosomatic unity of a specific patient narrows the diagnostic approach of the doctor, preventing him from understanding and seeing possible paths of therapy. Most often, such situations are encountered among doctors of surgical specialties.

The lack of experience and the ability of the physician to perform a subtle, non-standard and unconventional analysis in the search for causal relationships between pain and pathology of any organ, especially when minor disorders are detected in it, leads to the fact that many patients with abdominal pain of non-organic origin “turn from patients into victims of surgical excess” [strongorten-strongrivine J., 1986].

Classification of abdominal pain from a neurologist's perspective

In an attempt to systematize the existing types of abdominal pain, it is necessary to highlight those aspects that are within the competence of a neurologist. Psychovegetative and neurological mechanisms play different roles in the pathogenesis of one or another type of abdominal pain. However, a neurological view of this problem is becoming increasingly necessary given the achievements of both practical and theoretical neurology. Of course, between the classes of psychogenic abdominal pain and pain associated with organic diseases of the gastrointestinal tract, there is a whole group of abdominal pains in which neither psychogenic nor organic factors are obvious causes of pain. The proposed classification is based on the pathogenetic principle of psychosomatic unity in the broad sense of the word. The analysis is centered on the phenomenon of abdominal pain, and the analysis is carried out from the position of a broad neurological approach, taking into account the modern classification of vegetative disorders.

1. Abdominal pain associated with cerebral (suprasegmental) autonomic disorders
   • Abdominal pain of psychogenic origin
   • Abdominal pain of mixed nature (psychogenic with endogenous inclusions)
   • Abdominal pain as a manifestation of mental (endogenous) disease
   • Abdominal migraine
   • Epilepsy with abdominal seizures
   • Abdominal form of spasmophilia (tetany)
   • Abdominal pain in patients with hyperventilation syndrome
   • Periodic disease
2. Abdominal pain associated with peripheral (segmental) autonomic disorders
   • Solar plexus injury
   • "Gastric" tabetic crises
   • Porphyria
   • Abdominal pain of vertebrogenic origin
   • Multiple sclerosis
   • Syringomyelia
   • Tumors of the brain and spinal cord
3. Abdominal pain due to gastrointestinal diseases of unknown etiology.
   • Irritable bowel syndrome.
   • Dyspepsia.

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).

Pathogenesis of 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.

Psychogenic Abdominal Pain - Diagnosis

Abdominal pain in abdominal migraine is most often found in children and adolescents, but is often detected in adult patients. As abdominal equivalents of migraine, abdominal pain may be accompanied by vomiting and diarrhea. Vomiting is usually persistent, imperative, with bile, does not bring relief; the pain is severe, diffuse, can be localized in the navel area, accompanied by nausea, vomiting, pallor, cold extremities. Vegetative concomitant clinical manifestations can be of varying severity, sometimes their bright manifestation forms a fairly clear picture of one or another variant of vegetative crisis. The duration of abdominal pain in these situations varies - from half an hour to several hours or even several days. The duration of vegetative concomitant manifestations can also vary. 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 contractions and spasms in the distal limbs (carpal, carpopedal spasms).

Psychogenic Abdominal Pain - Causes and Symptoms

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