Handbook of Functional Gastrointestinal Disorders

Kevin W. Olden, Kevin W. Olden

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781000148428
• Edition: 1
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Presenting an integrated, multidiciplinary approach to understanding functional gastrointestinal (GI) disorders, this unique reference provides a comprehensive survey of esophageal, gastric, and colonic diseases known to have a strong behavioral or psychosomatic component-detailing the latest technologies used to assess these disorders from both a gastroenterologic and a psychologic perspective.

1

Overview of the Integration of Gastroenterology and Psychiatry

Kevin W. Olden

University of California, San Francisco and St. Mary’s Medical Center San Francisco, California

I. Introduction

When George Engel proposed the “biopsychosocial” model of disease, he concluded, as a foundation of the model, that all disease processes were influenced by physical, social, and psychological variables that interacted in a complex manner to produce the symptoms and end-organ damage observed by the physician (1). Likewise, physical illness can give rise to a spectrum of emotional reactions, which in turn can complicate efforts by caregivers to render treatment, as well as the ability of the patient to participate in that treatment. Few areas in medicine exemplify these principles better than the functional gastrointestinal (GI) disorders. Standing squarely at the interface between biomedical and behavioral science, the functional GI disorders have always proven to be a fascinating and challenging area of gastroenterology. For the clinician to be effective in treating patients with functional GI complaints, especially those that are refractory to standard medical treatment, an understanding of the strong interaction between psychological distress and physical symptoms is imperative.

The complex interactions among the physical, psychological, and socio-cultural dimensions in an individual’s life can take many forms. Patients who have endured extraordinary psychological stress such as childhood sexual abuse can develop a wide spectrum of physical and psychological disorders. Physical disorders include irritable bowel syndrome (IBS) and refractory low-back pain (2-4). An excess prevalence of psychiatric disturbance has also been shown in these patients, including depression, anxiety, personality disorders, and somatization (5,6). Disorders of sexual function are also commonly seen (7). The clinician who treats patients with functional GI disorders is thus presented with the formidable task of effectively dealing with a patient who often has a vague, ill-defined somatic complaint in the absence of any obvious structural or physiological abnormality. This can be a challenging situation for the physician. Failure to correctly evaluate psychosocial stressors and concomitant psychiatric diagnosis can result in redundant workup to uncover the cause of the complaints, poor symptom relief, and overuse of medical services.

Despite a rich body of literature documenting a strong overlap between functional GI disorders and emotional distress, clinicians often feel particularly vulnerable when dealing at the interface of these two areas of medicine. All too often, this interface can be quite perplexing if not distressing for the physician. This sense of uncertainty often leads to physicians’ being frustrated and unfulfilled in their care of the patient This discomfort stems directly from an inability to easily integrate biological, psychological, and social variables. However, physicians have not always been so ill at ease integrating biopsychosocial variables, as demonstrated throughout history. Functional gastroenterological disordera—indeed, psychosomatic medicine at large—can conveniently be said to have evolved through four distinct historical stages: ancient thinking, early psychoanalytical thinking, early psychophysiological research, and contemporary functional gastroenterology.

II. Ancient Thinking

Ancient societies were severely limited in their study of medicine by their lack of technological tools to investigate biological and chemical processes of the living organism. Likewise, the concept of the scientific method, with its demand for precision, would not be developed for centuries. Finally, the ancients did not have the luxury of building on the observations of those who had gone before them. This innocence, retrospectively, may be viewed as a stroke of good fortune in that ancient scholars were free to develop their own conceptual models of health and disease. A model of disease that reflected the importance of both the spirit and the mind along with the physical body in the development of illness was advocated by the ancient Greeks. Indeed, Hippocrates wrote, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Behavioral as well as physical symptoms were given great credence and reflected the spiritual/emotional roles as well as the physical roles that various organs played within the body. The concept was also strongly held by Plato, who wrote, “This is the great error of our day, that physicians separate the soul from the body.” Behavioral manifestations of disease were considered both logical and understandable; the ancients were very comfortable in ascribing them as being symptomatic of physical disease and vice versa.

The major deficiency in this line of thinking was that it was based only on anecdotal observations and philosophical constructs, which resulted in conceptual models with no real supporting data. This purely philosophical approach to medicine continued up to the time of the Renaissance, when two significant developments occurred that profoundly changed the course of medicine. The first development was the practice of organ dissection and the founding of the sciences of anatomy and physiology. While these events were critical to the foundations of modem scientific medicine, the tendency to describe disease processes only in terms of their observable morphological, structural, and physiological changes began a trend that tended to dismiss psychosocial issues as being irrelevant to the development of disease. The early work of Harvey in describing the circulation of the blood, followed by Koch and Pasteur’s pioneering work in bacteriology, revolutionized medicine. The by-product of this wave of discovery was a steady erosion of the perception that disease could result from psychological and social stressors.

The second development that impacted psychosomatic medicine during this period was the concept of “dualism” as proposed by mathematician-philosopher René Descartes. He advocated the concept that mind and body functioned in two completely separate spheres. Descartes believed that the cognitive functions of the body, the res cogitans, was completely separate from the body exclusive of the mind, the res extensa. However, Descartes himself retained some notion of mind-body interaction in that he believed the tiny pineal gland was the focus of mind-body communications (8). This rigid separation of mind and body, as proposed by Descartes and shaped by a number of his contemporaries, firmly established the notion of a separation of mind and body. The concept of dualism became a predominant theme of medicine for the next three centuries. The natural tendency was to focus on areas of medicine that were producing advances in knowledge and to avoid those areas that showed little advances.

Undeniably, from the seventeenth century to the present, there has been steady progress in our understanding of the biomedical dimensions of disease. The development of the scientific method of investigation, and the institution of new standards of scientific rigor such as Koch’s postulates, created a strong respect for a biomedical approach to disease.

The biopsychosocial model was at a distinct disadvantage during this period. The absence of methods technologically advanced enough to accurately investigate complex functions of neurophysiology and gut physiology further perpetuated this dualistic approach to medicine. Behavioral disturbances could be described only through observations as opposed to being measured scientifically. The inability to apply a biomedical approach to behavioral illnesses led to their being reclassified essentially as moral or spiritual defects. Indeed, disorders with a complex organic basis but with primarily behaviorally based clinical signs, such as epilepsy or Huntington’s chorea, were ascribed to “possession” or other acts of God or the devil. Behavioral abnormalities and physical symptoms that could not be explained by an identifiable organic lesion were relegated to nondisease status. Stigmatization of these patients led in turn to a wide variety of unfortunate consequences, including institutionalization and, in some instances, execution. What resulted universally was the exclusion of these patients from hospitals and from scientific study. A few courageous physicians tried to promote a “moral,” nonstigmatizing approach to the treatment of patients with behavioral disorders. This approach was championed by Benjamin Rush in the United States and Pinel in France. Their ideas enjoyed only limited support in the nineteenth and early twentieth centuries (9).

The work of William Beaumont with his patient Alexis St. Martin in 1883 was a key event in the history of psychosomatic medicine (10). This was true for a number of reasons. First, Beaumont’s work occurred at a time in history when dualism was in its ascent. Second, his work was conducted in accordance with the high scientific standards being set by Jenner, Koch, and others. Beaumont’s eloquent studies documenting the relationship between behavior and emotion, and its effect on gastric secretion, struck a strong chord for an integrated psychosomatic approach to the study of gut function. The response of St Martin’s stomach secretions to his temperamental mood swings were carefully recorded and documented. Beaumont’s exquisite use of the scientific method was widely acknowledged, and his astounding results were greeted with great excitement. This important use of the scientific method as applied to stress-induced changes in gut function, however, did not change the general direction of nineteenth-century medicine. The march continued toward dualism, i.e., “true” diseases that could be explained by anatomical abnormalities versus conditions that could not.

III. Psychoanalytical Thinking

The revolution in psychiatry and psychology created by the work of Sigmund Freud and others paradoxically furthered the move toward dualism. Freud was keenly aware of the impact of emotions on the gut. Believing that oral and anal functioning were some of the most important bodily functions, he theorized that they were greatly related to psychological processes. His recognition that alimentary function was strongly influenced by psychosocial development created great interest (11). The major difficulty with the work of the early psychoanalysts was that, like that of the ancient Greeks, their work was all too often based mainly on empirical observations and theoretical speculation. Freud’s concept of “conversion hysteria” stated quite forcefully the theory that psychological distress (conflict) could induce dramatic physical symptoms. Freud believed that a conversion reaction was the result of an unconscious psychological conflict expressed through dysfunction of the voluntary striated muscle innervated by the peripheral motor nerves simulated by the cerebral cortex (12). Sandor Ferenczi first applied the concept of conversion disorder to organs innervated by the autonomic nervous system. Ferenczi first proposed the concept that ulcerative colitis, and specifically the bleeding of ulcerative colitis, was the result of an “autonomic conversion disorder” (13). This concept was extended one more step when George Groddeck and S. Ely Jelliffe proposed that physical signs such as fever, jaundice, and hemorrhage could repress symptoms of unresolved “conflict” and therefore represented a conversion disorder (14).

An attempt to improve on this early psychoanalytical thinking led to the work of Franz Alexander and colleagues at the Chicago Psychoanalytic Institute. Their work, which became known as the “Chicago school,” made a number of bold assertions as to the psychological basis of a wide spectrum of medical illnesses. Unlike Freud and the other early psychoanalysts, Alexander believed that psychosomatic disease resulted from the effect of prolonged psychic stress on end organs. This stress resulted from the inability of patients to resolve certain types of unconscious psychic conflict. These specific conflicts, mediated by the autonomic nervous system, led to dysfunction in certain organ systems based on the type of stress and the patient’s coping style. The relationship between the inability to handle specific kinds of psychic conflict and the presumed tendency of certain types of maladaptation to produce injury to specific organs was dubbed the “specificity theory” by Alexander (15).

Alexander conceptualized seven “psychosomatic diseases”: asthma, rheumatoid arthritis, thyrotoxicosis, essential hypertension, neurodermatitis, peptic ulcer disease, and ulcerative colitis. The fact that two of the seven conditions were GI disorders again demonstrated the belief that the gut was particularly sensitive to stress-induced dysfunction. The specificity theory was developed from open-ended interviews with patients who had various “psychosomatic” diseases. Again, the conclusions reached were based on work subject to extraordinary observer bias and anecdotal observation. For instance, Alexander and coworkers’ description of the vulnerability of various ethnic groups to peptic ulcer were stereotypical and based on racial and religious bias. His conclusions are quite difficult to accept when viewed with our current understanding of peptic ulcer disease. Alexander’s work has subsequently come under intense criticism in reviews of his methodology and conclusions. Helzer and colleagues in a controlled trial demonstrated a lack of association between premorbid psychological state and the subsequent development of either Crohn’s disease or ulcerative colitis (16,17). This was particularly true of the characterization of patients with ulcerative colitis as having the “somatic manifestation of melancholia,” conflicts about “sexual relationships or marital relationships,” and the “frustrated tendency to carry out an obligation” (18). North and colleagues have written eloquently on this topic (19).

These events were occurring at a time when internal medicine was making dramatic advances in describing the physiological basis of disease, including ulcerative colitis and peptic ulcer disease. It became clear through the next three decades that a patient’s risk of developing inflammatory bowel disease and peptic ulcer disease was influenced by a host of biological factors. These developments contrasted sharply with the psychosomatic thinking proposed by Alexander and his coworkers. The net result was the development in medicine of a strong skepticism about the importance of psychosocial variables in the development of disease. This skepticism, in turn, created a further schism between those pursuing a purely biomedical approach and those invested in a more biopsychosocial construct of disease.

IV. Psychophysiological Research

Improvements in technology in the late 1940s subsequently led to a series of classic studies in gut physiology. The develo...