AUSTIN McCAWLEY, M.D.

Managing psychosomaticabdominal pain

Dr. McCawley is director of the department ofp.~vchiatrvat Saint Francis Hospitaland Medical Center in Hartford. Conn. Reprint requests to Dr. McCawley at thehospital. 114 Woodland Street. Hartford. CT 06105.

ABSTRACT: Complaints of abdominal pain caused by psychologi­cal disorders are extremely common in clinical practice. Thispaper discusses psychological diagnosis and therapy, with em­phasis on the role of the family physician. Acute and chronicsyndromes are described. The author recommends family ther­apy as an effective treatment that should be used more often.Close collaboration between primary physician, psychiatrist, andsurgeon is essential. The push toward surgery (which often comesfrom the patient) should be resisted to allow adequate time forpsychiatric intervention and to avoid unnecessary surgery.

Complaints of abdominal discom­fort caused by emotional upset arefrequent. Gastroenterologists maysee at least one new such patient aday, and some family practitionersdescribe a similar frequency. Thenumber of such patients is verylarge indeed, if it includes womenwith chronic pelvic pain who haveno discernible pathology, and pa­tients with such conditions as ul­cerative colitis which, althoughprobably not psychogenic, are as­sociated with emotional factors.

The frequency of abdominal andpelvic disorders associated withemotional upset is not hard to ex­plain. First, organs in these areasare innervated by the autonomicnervous system and therefore arelikely to be implicated in stress re­actions; and second, the functionsof nutrition, excretion, sexuality,and reproduction have profoundemotional significance for the indi­vidual, in relation to both his cur­rent experience and his childhoodmemories.

Diagnostic types

The diagnostic categories of distur­bance are many and varied. Amongthe clearly psychogenic conditionsare conversion reactions, hypo­chondriacal neurosis, somaticsymptoms of depression, somaticdelusions of schizophrenia, and thepsychophysiologic disorders. In thelatter, one organ becomes the focusof excessive anxiety, with resultantphysiologic change. Nausea, vom­iting, dysphagia, dyspepsia, spasticcolon (the irritable bowel syn­drome), aerophagia, diarrhea, andconstipation may all be psycho­physiologic reactions.

Duodenal ulcer and ulcerativecolitis are conditions in which emo­tions are important influences, al­though their basic etiology involvesother somatic processes.

At the other end of the scale areseveral physical illnesses, clearlyorganic in origin, which are oftenaccompanied by very definite psy­chiatric disturbances. These in­clude carcinoma of the head of thepancreas, which produces depres­sion; hepatitis, which can produce avariety of psychiatric symptoms,

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Abdominal pain

especially at onset before the diag­nosis is clear; metabolic encepha­lopathies such as porphyria, whichcan mimic almost anything; andCrohn's disease, which has a signif­icant psychiatric component.) In aspecial category are those com­plaints attributed to adhesions fol­lowing surgery.

Chronic pelvic pain, characteris­tically a constant, dull, aching painin the suprapubic region or in oneof the lower abdominal quadrants,is included in this discussion. Fre­quently seen by the gynecologist, itis responsible for a great deal ofneedless surgery.

Psychological diagnosis

If the initial interview reveals sig­nificant depression, schizophrenia.or another major psychiatric syn­drome, then management dependson that diagnosis. In practice, how­ever, the psychological diagnosis isnot always clear-cut. For example:most patients in distress show someform of depression; depression andhysterical conversion reactions canbe present at the same time; hys­terical patients rarely show theclassic belle indifference; and psy­chophysiologic reactions are ac­companied by a variety of otheremotional symptoms.

Office patients with acute symp­toms usually are anxious to discusstheir concerns and so the underly­ing problems become clear. This isnot always the case, however, andsometimes it can be very difficult toreach an understanding of the psy­chological basis for the symptoms.

Theories about psychosomaticillness have changed considerablyover the last 25 years. Earlier theo­ries attributed the psychosomaticconditions to specific dynamic con­flicts. For example. peptic ulcer wasassociated with problems of depen-

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dency, and hypertension with sup­pressed anger. Current theory takesa broader view of the factors thatinfluence the personality and of theconstitutional predisposition of theindividual to produce disease.Studies indicate that one importantprecipitant is the loss of ability topredict and control a threateningenvironment.2 When this occurs,the organism alternates betweenfruitless struggle and surrender; thelonger this cycle persists, thegreater the risk of illness.

The aim, therefore, is to getbeyond the diagnosis to reach acomplete understanding of the in­dividual, including family rela­tions, intrapsychic conflicts, physi­cal disease, heredity, constitution,and sociocultural factors. In thiscontext, the intricacies of psychiat­ric diagnosis become less impor­tant. It is more important to get tothe "guts" of the situation-and thepun is intentional-than it is to tryto construct a neatly formulatedand theoretically satisfying psycho­dynamic explanation.

Everything that has been saidpresupposes that a complete physi­cal examination has been done andthe results explained to the patient.It is worth remembering that thepatient can have an obvious psy­chiatric illness and also an unre­lated concurrent physical disease.

Therapeutic approach

In therapy, the most important dis­tinction is made between acute andchronic psychosomatic conditions,with a further distinction betweenthose recurrent ills which affectfunctioning personalities and thosechronic disabling illnesses whichbecome a way oflife for the person.

Acute syndromes: The best re­sults are obtained in patients withacute conditions. In many cases,

these are resolved very satisfacto­rily in the physician's office. After acareful physical examination hasexcluded organic disease and thepatient has been so informed, thepatient is often glad to unburdenhimself or herself. (In advising thepatient that no physical disease hasbeen found, the physician shouldnever say, "There's nothing wrongwith you; it's all in your head.")Once the underlying emotionalproblems have been ventilated andperhaps some appropriate symp­tomatic treatment prescribed. thepatient improves. A physician'ssympathetic and psychologicallyaware attitude is important. Even ifthe psychological problems are notventilated, some patients respondto the supportive and reassuringaspects of the consultation.

When the patient has a recur­rent, persisting problem with occa­sional acute exacerbations-andthis applies often to the irritablebowel syndrome-complete recov­ery cannot be expected, but veryconsiderable relief of acute epi­sodes can be expected. The patientwith the spastic bowel may con­tinue to have some symptoms on achronic basis, and this must be al­lowed for; in fact, the physicianalmost gives the patient "permis­sion" to have symptoms but helpsto control them and to avoid orminimize the more distressingrelapses.

The problems are not alwayssolved so easily, however. Somepatients are blocked and defendedagainst any awareness of underly­ing problems. Psychological con­flicts and difficulties are displacedonto the physical symptoms andthere is no response to psychologi­cal inquiry, even in the presence ofobvious situational and personalproblems that ordinary common

PSYCHOSOMATICS

sense would regard as very sugges­tive of emotional stress. Nemiahand Sifneos3 have described the in­ability of many patients with psy­chosomatic illness to express emo­tion, fantasy, and psychologicalexperience of all kinds, a charac­teristic which they have calledalexithymia.

At this point, the interviewingskills of the physician are tested.The most common errors are fail­ure to take a complete detailedpersonal, social history over severalinterviews; misuse of direct, chal­lenging questions; and a tendencyon the part of the physician to de­velop premature expectations ofsome favorable response.

Patients who have erected rigiddefenses against the awareness ofpainful emotions do not relax theirdefenses simply because a physi­cian asks them a direct question;instead, they react by strengtheningtheir defenses and increasing theirdenial. Instead of directly askingwhat was going on at the time thetrouble began, the physician findsout by taking a careful history,using questions that establish factsand experiences, and avoiding anyattempt to link cause and effect.When the story is known, then theconnections start to appear to bothphysician and patient. Withoutpressure, the patient can see thepossibility of some emotional reac­tions, and the physician may haveto say very little. When more activeintervention and interpretation bythe physician are necessary for themore resistant case, the back­ground has been established thatwill give force to whatever expla­nations the physician may give, andit is harder for the patient to avoidfacing the emotional realities.

In obtaining the history, non­verbal communication is impor-

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tant. If the patient clenches a fist,tightens the jaw muscles, or dis­plays any of the numerous physicalmanifestations of emotion duringparts of the story, then that is animportant communication whichcan be reflected back to the patientfor consideration.

With the more reserved patientsand also with certain culturalgroups, the catharsis does not haveto be a dramatic outburst. Somepatients will discuss very painfulemotions and experiences with re­straint but with a great deal offeeling-it may be the first time thepatient has ever unburdened him­self or herself. For another type of

Several physical illnessesaffecting the abdominal areaare accompanied bypsychiatric disturbances.

personality, the brief admission ofunderlying feeling may be an at­tempt to dismiss the subject, andthe physician will handle it dif­ferently, following up the matterdiscreetly.

Even the most insightful and ac­curate psychological approachesare not going to produce dramaticresults, and if the therapist hasgrandiose and premature expecta­tions of improvement, everyone isgoing to be disappointed. Whathappens if the treatment succeedsis that the symptoms gradually re­cede into the background and theinterviews shift to other topics con­cerned with emotional issues. Oncethe therapist has made an accurateevaluation of the psychological sit­uation, he or she should decide onthe approach to take and shouldthen hold to that course. This takesa certain kind of courage, particu-

larly if the patient is demandingsome other kind of medical or sur­gical treatment. Cooperationamong the various physicians in­volved is essential to avoid prema­ture decisions.

Chronic psychosomatic illness

The treatment ofchronic psychoso­matic illness is a different proposi­tion. Two types of patients are in­volved-the suffering butfunctioning patient and the chron­ically disabled.

The functioning patient: Thistype of patient has chronic or regu­larly recurring symptoms but is stillable to cope with the business ofliving. Such patients tend to becompulsive, anxious personalitieswho overreact to stress and seem tocreate their own particular type ofstress. As the history unfolds andthe physician gets to know the pa­tient, a number of psychologicaland personality problems appearand may indicate a need for psy­chiatric referral. The types of syn­dromes involved include the irrita­ble bowel syndrome, chronic pelvicpain without organic pathology,hypochondriacal neurosis, chronicgastritis, and some peptic ulcerswith psychological components.

Detailed exploration of the psy­chological problems of the patient,either by the primary physician orthe psychiatrist, more often thannot fails to produce any improve­ment to match increased under­standing. In fact, if understandingis pushed too quickly, the patientmay even get worse. In these reac­tions, the patient is not just re­sponding to specific emotional ex­periences and conflicts but is alsoshowing habitual learned patternsof behavior that produce symp­toms. Therefore, any attempt tounderstand and express emotional

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Abdominal pain

difficulty has to be accompanied byan attempt to "unlearn," or at leastmodify, the conditioned behavior.The behavior is shaped by anumber of contingencies includingincreased anxiety responses, mech­anisms to avoid anxiety, attentiongetting, dependency needs, and ag­gressive maneuvers.

The factor of increased anxiety isa common denominator in most of

The aim is to get beyond thediagnosis to reach acomplete understanding ofthe individlUll.

the cases, and the pattern of in­creased anxiety response has to beunderstood as a learned response aswell as a psychodynamic symptomwith individual meaning. This in­dicates that psychodynamic inter­vention may be useful for somepatients but by itself will not besufficient. In many patients it issimply not indicated. It is necessaryto deal with the habitual anxietyand desensitize the patient througha more behavioral approach.

The way to do this is not bytelling the patient to stop worrying,take it easy, relax-or by other su­perficial bromides. The patient hasto be shown, through the mediumof relaxation techniques. The tech­niques are quite simple, and anyphysician working with psychoso­matic problems should become fa­miliar with them or, failing that,find someone competent in suchtechniques to whom to referpatients.

The methods involved includethe Benson relaxation technique,4hypnosis, Transcendental Medita­tion, and the progressive relaxationtechnique of Jacobson.s The essen-

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tial features in all these methodsare focusing concentration, exclud­ing extraneous stimulation as muchas possible, and progressively re­laxing the voluntary musculature.

Recently biofeedback training topromote relaxation has signifi­cantly helped a small number ofpatients with irritable colon treatedin our group. Biofeedback tuned tospecific physiologic variables, suchas bowel sounds, was not helpful,but a less specific biofeedback ap­proach focused on muscular relax­ation was very successful.

The disabled patient: This is achronic patient who has adoptedillness as a way of life. There maybe real organic pathology in somecases, perhaps secondary to psy­chophysiologic processes, perhapssecondary to futile surgical proce­dures; but the degree of pathologyis not commensurate with the dis­ability involved.

The symptoms are not confinedto the abdominal area. They in­clude physical symptoms in mul­tiple areas of the body, and behav­ioral disturbances such aswithdrawal, depression, apathy, ir­ritability, nervousness, anddependency.

The personal history will revealcircumstances and psychologicalinfluences that have shaped thisbehavior. The histories reflect suchproblems as emotional rejection,illness modeling from a parent,earlier experience with physical ill­ness, learning experiences that con­firmed the person in a helpless role,deprivation of various kinds, andsecondary gain and other kinds ofreinforcement for the sick role. Theproblems have usually operatedover substantial periods in the in­dividual's life.

Understanding these processes isuseful to guide the therapist but,

again, insight by the patient doesnot do very much to change thesituation.

The necessary approaches go farbeyond the competence of anyonephysician, for they include rehabil­itation, vocational training, psy­chotherapy, and behavioral ther­apy. An excellent description of thebehavioral approach for gastroin­testinal complaints is given byBlackwel1.6 In the more difficultproblems, treatment may be feas­ible only on an inpatient programwhere a team approach is available.

FamiZv involvement: It is alsovery helpful to work with the fam­ily. This approach has great poten­tial for the treatment of all thepsychosomatic problems men­tioned, including acute and chronicailments that do not respond to theordinary routine individualtreatments.

In the family interview, problemsthat were unrecognized or deniedby the patient become apparent. Ithas been my experience that manyresistant psychosomatic problemsbegin to clear as other issuesaround family relationships begin

The patient can have apsychiatric illness and anunrelated concu"entphysical disease.

to take precedence. The therapist,the family, and the original patientthen have to work toward someresolution of these interpersonalproblems.

Intensive family therapy is anundertaking for the therapisttrained in this modality, but a greatdeal of short-term therapy can bedone in limited contacts by the pri­mary physician, who will have to

PSYCHOSOMATICS

talk to the family in any event. It ismuch better to handle these familycontacts in a therapeutic way,rather than simply to relay infor­mation about the patient.

Specific syndromes

Irritable bowel: Some episodes ofirritable bowel syndrome respondvery well to the general approachoutlined under the treatment ofacute syndromes. The irritablebowel syndrome, however, tends tobe a relapsing or chronic syn­drome.7 Classic intensive psycho­therapy does not usually makemuch difference to the course of theillness. The treatment has to com­bine a good psychological evalua­tion of the patient, establishment ofa relationship, attention to stressfulcircumstances in the life situation,supportive measures, and relax­ation techniques. Family therapy isuseful for the more difficult cases; itis at least useful to see the familyand evaluate the need for familyintervention. The patient oftencontinues to have symptoms, but ifthese can be accepted and managedwithout too much distress, the pa­tient can be helped significantly.

Chronic pelvic pain: Problems ofchronic pelvic pain in women pre­sent more difficulties in treatment,at least in the early stages. Thepatients tend to be more blocked onthe psychological issues, and thealexithymia previously described isvery much a problem. As the issuesdevelop, they tend to be more com­plicated and sensitive, often in­volving sexuality, guilt, and maritalrelations. Involvement of the hus­band in treatment is often advis­able. There may be considerableresistance to psychiatric interven-

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tion, but it is much less if the initialpsychological exploration is ac­complished by the primary physi­cian, family practitioner, or gyne­cologist. The points already madeabout interview technique are par­ticularly valid in these patients; theapproach has to be slow and care­ful, letting the patient bring out theproblems at her own pace.

One of the major problems withchronic pelvic pain is the pressureto resort to surgery-and this pres­sure originates more often from thepatient than from the surgeon.Some patients seem extraordinarilydetermined to have their organs cutout. Suggestions about surgeryfrom the physician are important,of course, and cooperation amongthe psychiatrist, primary physician,and the surgeon is essential.Usually, psychiatric consultation isnecessary.

Adhesions: Similar consider­ations apply in abdominal painblamed on adhesions. In my expe­rience, once an abdominal pain hasbeen attributed to adhesions fromprior surgery, the patient becomesdetermined on further surgery.Unfortunately, it is usually not toohard to find a surgeon to oblige.

With good cooperation betweenthe surgeon and the physician who

REFERENCES1. SheHield SF. Carney MWP: Crohn's disease: A

psychosomatic illness. Sr J Psychiatry121:446-450. 1976.

2. Engel GL: Psychosomatic approach 10 individ­ual susceptibility to disease. Gastroenterology87:1085-1093.1974.

3. Nemiah JC. Sdneos PE: AHect and fantasy inpatients with psychosomatic disorders. in HillOW (ed): Modern Trends in PsychosomaticMedicine. London. Sutterworths. 1970. vol 2.

4. Benson H: The Relaxation Response. NewYork. Morrow. 1975.

5. Jacobson E: Progressive Relaxation: A Psy-

Abdominal pain

treats the patient psychologically,these problems can be handled.The possibility that adhesions arethe cause should not be mentionedunless there is clinical and radio­logic evidence of obstruction andan operation is definitely indicated.If the patient brings it up, then thediagnosis of adhesions should beplayed down as much as possibleuntil the other factors have beeninvestigated. It is worth remember­ing that adhesions are present inthe abdomens of many personswho have never had an operation,8and that an operation for adhesionswill cause more adhesions. Re­peated surgery on patients whoseabdominal complaints are psycho­logically based may ultimately pro­duce a real obstruction.

Peptic ulcers: Classic psychiatrictreatment of the peptic ulcer pa­tient has been quite unsuccessful inmost cases. Recent studies, how­ever, have shown that ulcer patientsrespond to very different types ofmedical treatment and that the im­provement seems to be unrelated tothe choice of treatment, indicatingthe importance of psychologicalfactors and the doctor-patient rela­tionship. There is more suggestioninvolved in what we do than we liketo admit. 0

chological and Clinical Investigation 01 Muscu­lar States and Their Signilicance in Psychologyand Medical Practice. 3rd revised ed. ChIcago.University of Chicago Press. 1974.

6. Blackwell B: Psychosomatic aspects of gas­trointestinal complaints. J Ky Med Assoc74:26-29. 1976.'

7. Orossman OA. Powell OW. sessions JT Theirritable bowel syndrome. Gastroenterology73:811-820. 1977.

8. Weibel MA. Majno G: Peritoneal adhesions andtheir relation to abdominal surgery. a postmor­tem study. Am J Surg 128:345-353. 1973.

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