Psychophysiologic Gastrointestinal Disorders in Children

Psychophysiologic Gastrointestinal Disorders in Children ADAM

J.

KRAKOWSKI,

• One of the most abused cliches still appearing in modern psychosomatic literature is that emotions and bodily functions are closely interrelated. Yet, psychosomatic mechanisms are rarely well understood. The vast majority of authors, while neither purely "organic" nor purely "psychological," attempt to integrate the psychodynamic with a neuro-physiological theory. The practitioner may not gain enough practical information from either the various theories proferred by our psychiatric forefathers of all orientations or from contemporary authors who assume no specific position. Even the definition of psychosomatic illness is still often confused. In a general sense, it is a somatic disorder which is at least partly caused by emotional factors; but even the novice knows that any somatic illness is "contaminated" by psychological concomitants and sequences. A psychosomatic illness, however, differs from conversion and from all other neurotic reactions whose symptoms include somatizations or organ expressions of mental processes. In somatizations, specific unconscious conflicts are symbolically expressed without any physiological alteration of the involved organs and certainly without any subsequent structural changes. But a psychophysiologic disorder which is basically physical in nature produces physiological, and finally structural changes when the process exists for a sufficiently long time. Moreover, the organs involved are under the involuntary influences of the autonomic nervous system. Unlike conversion which serves to "bind" and

Dr. Krakowski is Professor, Deparhnent of Medicine and Health Education and Consultant in Psychiatry, Plattsburgh State University College; Director, Plattsburgh Child Guidance Clinic, Plattsburgh, New York. Presented at The Regional I\leeting of The Academy of Psychosomatic Medicine and University of Florida College of Medicine, Gainesville, Florida, I\larch 17 1967. '

326

M.D.

"neutralize" anxiety, a psychosomatic illness does not perform this role at all. Finally, a psychophysiologic reaction affects one system or one organ, whereas neurosis may affect many organs. In short, a psychosomatic illness is a somatic sequence of persistent untoward emotional causes, affecting the viscera and organs under control of the involuntary autonomic nervous system; its symptoms are physiological and not symbolic; it cannot alleviate anxiety; and it leads to eventual structural changes within the same organ which originally became affected. The interaction of the mind and the body involves a person as a social creature with ever-changing features on the one hand, and his physical organism with its genetic background on the other. The organs affected are those regulated by the autonomic nervous system and also influenced by the endocrine system, particularly its adrenergic and the cholinergic components. The autonomic nervous system maintains homeostasis through its regulatory effect on digestion, cardiocirculatory functions, respiration and excretion. It is also responsible for the organism's defense in danger. These functions may be either synergistic or antagonistic, i.e., may lead to either strengthening or weakening of defenses with resulting increased or decreased ability to withstand the danger.! The chronic disturbances may lead to dysfunction and finally to tissue reactions resulting in structural changes. It has been experimentally proven that the mediation between the psychological stimuli and the viscera is accomplished through the cortical- hypothalamic -pituitary - adrenal and vagal sequences responsible for the organism's defense in danger. The hypothalamus is said to be the regulatory super-structure translating, mediating and regulating the emotional stimuli into the endocrine responses. The hypothalamus is seen as the reactor to, as well as a stimulator of the cortex, the reticular activatVolume VJII

GASTROINTESTINAL DISORDERS-KRAKOWSKI

ing system and the endocrine apparatus. 2 It is also connected with the limbic system which is sensitive to feelings and responsible for selfpreservation.:! It exerts influence upon the visceral requirements on the one hand and the excretion of ACTH on the other. Other parts regulate sex hormones and sex behavior. The adrenergic activity is understood now in the light of influences of adrenalin and noradrenalin, the fonner being involved with fear and anxiety and the latter with the states of rage and hostility.. The adrenal corticosteroids, on the other hand, are involved in protecting the tissues against traumatic and inflammatory influences. Thus, failure in these functions may be responsible for structural changes. Furthermore, it is also postulated that the adrenergic honnones are indirectly involved in stimulating secretion of the steroids. In discussing the psychological factors involved in the formation of psychosomatic illness one may say that the psychological adaptation also has its roots in the phenomena which are like homeostatic mechanisms." Failures occur in those individuals whose defensive qualities are inadequate because of an inability to cope with prolonged stresses and conflicts, or those whose defenses weaken because of an inadequate environmental support. This seems to occur in such individuals who show serious ego-weakness leading to regressive defenses because of a disturbed parentchild relationship. Under the influence of prolonged stresses the psychic homeostatic equilibrium becomes so disturbed that such individuals become incapable of warding off anxiety. Physiological defenses seem to be set in motion concurrently, or to take over when the psychological defenses fail to protect the individuaI.G The choice of the organ may be detennined by genetic factors with predominance of either sympathetic or parasympathetic activity, or disordered autonomic activity linked with the psychogenic defenses. Sympathetic predominance may result in hypertension, vascular headaches or hyperthyroidism; the parasympathetic type is manifested by bronchial asthma or gastrointestinal disturbances. Attention should be drawn also to allergic, toxic, nutritional or other such causative factors. Certain conditions such as, e.g., bronchial asthma and ulcerative colitis may he originally November-December, 1967

caused by these factors. It appears that the emotional stress engendered by these factors, will in the presence of certain genetic and psychogenic predispositions and/or concomitants eventually produce such psychological and physiological sequences that the illness will finally become psychophysiologic. GASTROIl'\TESTINAL DISORDERS

The psychological components of the psychophysiologic gastrointestinal disorders are easy to understand in the light of the role of feeding and its meaning in early life. The child's physiological and psychological dependence upon his mother and the fulfillment of his instinctual needs are achieved through oral gratification, eating and evacuation. Thus, fulfillment of the instinctual needs through feeding accomplishes a nonnal physiological function and gives rise to primitive satisfaction and security. Frustration may signaliz(' danger and become symbolic of rejection; it may be a source of struggle and a root of aggression. Psychophysiologic responses to negative environmental influences are in rapid sequence, as if the gastrointestinal tract possessed a barometric property of responding to the maternal climate. Thus dysphagia, cardiospasm, pylorospasm, colic, constipation, etc., which occur, constitute simple, though t ran sit 0 r y psychophysiologic dysfunctions. Peptic ulcer and ulcerative colitis are examples of severe reactions in which serious structural changes occur." Here too, certain confusion still exists in the diagnostic nosological approach, especially because children with psychophysiologic disorders do tend to display other concurrent but unrelated symptoms that make the predominant clinical picture difficult to identify. The following classification offered for consideration is based on a long tenn observation of 74 children o and of the treatment of 49 of °This is a part of a large long-range study in a Child Guidance Clinic including various forms of adjustment read ions of childhood and adolescence whose certain aspects were previously reported. Most of the cases were referred by either family physicians or pediatricians following unsuccessful treatment trials with the usual office and hospital procedures. In this study the referring physicians remained in partnership with the Clinic, both in treatment and follow-up of the children. Only those children were included whose primary illness was psychophysiologic; psychophysiologic components of behavior disorders were (·xcluded. R' ll

327

PSYCHOSOMATICS

these children. l l 1. Psychogenic (psychophysiologic) vomiting. 2. Chronic epigastric pain and gastritis. 3. Peptic ulcer. 4. Psychogenic ( psychophysiologic) diarrhea. 5. Psychogenic (psychophysiologic) megacolon. 6. Ulcerative colitis. PSYCHOGENIC (PSYCHOPHYSIOLOGIC) VOMITING

This group of 12 boys, ranging from early school age to puberty, were patients whose conditions lasted for extended periods as a result of chronic and environmental stresses. It did not include children displaying somatizations accompanying various neurotic reactions. The attacks of vomiting were frequent, not necessarily postprandial but were triggered by even minor exogenous stresses and were refractory to dietetic and usual therapeutic measures. Pain was conspicuously absent. Antiemetics were not useful although phenothiazines in large doses were temporarily effective. The affected children displayed many other symptoms, common in adjustment reactions of childhood. They were anxious, hyperactive and hostile. Intelligence was low to average. All showed a distinct inability to adjust to peer groups and to siblings and all were scholastic underachievers. They belonged to lower middle class, poorly adjusted families with a distinct tendency to marital disharmony. Mothers were rejecting and dominant, the fathers withdrawn and disinterested and frequently absent from home. CHRONIC EPIGASTRIC PAIN AND GASTRITIS

In another group of 40 children, 24 (15 boys) were diagnosed as chronic epigastric pain and 16 (12 boys) as gastritis according to the roentgenologic findings. The chronicity and the severity were almost equal, though the parents tended to describe the seriousness of those with gastritis as more pronounced. This was probably reinforced by the fact that all children with gastritis and only half of those with epigastric pain were previously hospitalized. Both groups showed a relatively higher level of intelligence than those diagnosed as psychophysiologic vomiting; only ap328

proximately one-half of the entire group were scholastic underachievers, although their absenteeism was more frequent and longer. The majority ranged from nine to 12 years; all were refractory to previous therapy, although they showed a tendency to temporary remissions during hospitalizations. The children were shy, timid, anxious but less hyperactive; they were more competitive, more self-contained and withdrawn than those with psychophysiologic vomitin~. During exacerbations of illness they appeared depressed. Nausea, vomiting, headaches and sleeplessness were present in about one-half of those with epigastric pain and in two-thirds of those with gastritis. They showed less tendency to vacillate between appearing healthy during the quiescent periods and appearing ill during exacerbations than the former group. Behavior disorders were also less frequent. Their families appeared more stable though marital disharmony was pronounced. The mothers were less verbal, but were overprotective and defensive. The fathers were withdrawn, passively rejecting and submissive to their wives; they visited the clinic rarely, if ever. PEPTIC ULCER

This group of five boys and three girls ranged in age from six to 12 years. All cases but one were radiologically confirmed. Symptoms were almost identical in all. All patients were refractory to extensive treatment prior to referral, although most showed symptomatic remissions during hospitalizations and relapses after discharge. These were at least of average intelligence and approximately one-half were bright to superior; one-half were scholastic underachievers. All boys were introversive, timid and withdrawn; girls were shy, but somewhat more outgoing. Most showed a tendency to selfishness and passivitv. They were not sought by peers and few had friends; the boys were passively obstructionistic at home and generally hostile towards their siblings. During the attacks these patients were anxious, depressed, and at times prostrate. They demanded their mothers' attention but were not affectionate. Their parents were middle-class people with rather high social aspirations, either college educated or with good incomes. The fathers were generally submissive to wives but domiVolume VIII

GASTROINTESTINAL DISORDERS-KRAKOWSKI

neering with patients; the mothers were compulsive, domineering, jealous, frigid and overprotective with their children. PSYCHOGENIC (PSYCHOPHYSIOLOGIC) DIARRHEA

This group consisted of seven boys and one girl ranging from six to 13 years. Their personality characteristics resembled those with peptic ulcer, but their reaction to illness was less severe in terms of school absenteeism and the rate of hospitalizations. Their average intelligence was also lower than that of those children with peptic ulcer. Scholastic underachievement was comparable. The concurrent emotional maladjustment was of the self-contained type with tendency to dysphoria and sleeplessness. The frequency of bowel movement was from three to 14 a day; pain was present rarely, and usually preceding or during bowel movements which were loose to watery; mucus and slight blood streaking were rarely present in stools. Roentgenographic studies never showed any true structural changes, but signs of hypermotility of the small and large bowel were frequent. All children showed a history of enuresis and soiling which were terminated from one to five years prior to the onset of illness. The parental group represented a relative similarity to those observed in peptic ulcer patients, but the mothers were less rejecting and more overindulgent, while the fathers were absent from home because of work activities. All families showed a history of having moved to a new environment prior to the onset of illness. PSYCHOGENIC (PSYCHOPHYSIOLOGIC) MEGACOLON

Four boys and one girl ranging from two to eight years represented this group. One 2year-old boy previously diagnosed as aganglionic megacolon had been subjected to surgery when less than one year of age. At two he again developed megacolon, but a thorough study, including a second biopsy failed to reveal a neurologic disease. The patient displayed no concurrent behavior disorder and his parents appeared well-adjusted. Aganglionic megacolon was ruled out in the remaining children by radiological studies. All children were persistent soilers, but none showed enuresis. Constipation was continuous and severe. The colon, overfilled with fecal November-December, 19S7

material, could not empty unless enemas were given; cathartics were rarely useful. Spontaneous, partial bowel movements occurred every 4 to 12 days. With the exception of the 2-year-old boy, all children were emotionally immature for their age, overdependent upon their mothers, hyperactive, stubborn, obstructionistic, jealous, hostile and aggressive to siblings and peers. Intelligence varied from borderline to average. Scholastic underachievement with reading disability was pronounced in those who were of school age. The history of bowel training in the patients revealed laxity rather than tendency to coercion, at least until the megacolon was developed. After a thorough "cleaning" with enemas those children usually showed a considerable improvement with a normal bowel activity for a few days and a distinct improvement in affect, attitude and behavior; a few days later a new constipated cycle started. Mothers were predominantly domineering, unhappy and disillusioned in marriage, rejecting the patient and expressing direct guilt. The fathers were uninvolved. ULCERATIVE COLITIS

This is a severe illness, apparently on the rise in this country, whose etiology is not completely understood, though psychogenic factors are said to play an important roleY Most studies published seem to stress that personality characteristics are similar to those seen in obsessive-compulsives with affective rigidity, infantilism, immaturity, hypersensitivity, obstructionism, self-centeredness and overdependency. The ages range from early childhood to mid-adolescence. The onset of illness is often ushered in by an acute stressful situation of an exogenous type. The mothers are said to be rigid, dominant, overindulgent or overprotective. In our own series we saw only one child with ulcerative colitis. This child presented all "typical" characteristics involving the background, the personality and the circumstances of onset. This 6-year-old girl developed a moderately severe ulcerative colitis with eight to 16 bowel movements a day with a moderately severe blood loss, after her father, a chronically maladjusted schizoid individual in his late twenties, committed suicide. 329

PSYCHOSOMATICS COMMENT

In this group we were unable to find any definite common personality characteristics, identity of behavioral disturbance or phychodynamics. The similarity of the disturbed parental influences was somewhat more evident. The disturbed parent-child relationship was definitely present but the surface scrutiny could not distinguish it readily from such abnormal relationships which are also responsible for neurosis in children. One must assume that the chronic psychologic maladaptations coupled with the lack of parental support have rendered the children doubly vulnerable to the added stresses produced by the environment. Perhaps the genetic or other disturbed physiological functions do result in increased disequilibrium and lead to further physiological reactions. The altered organ responses produce then a clinical picture of psychophysiologic illness. These factors were confirmed by the treatment trial of a group of 49 children selected from the entire group reviewed above. In this group, irrespective of the method used, a strong effort was made to alter the negative environmental influences through group or individual therapy and counselling with the parents. The objective of this part of the treatment was to remove those untoward influences which had caused the psychologic maladaptation of the child and to improve parental support. Of the total group the following categories were treated: psychophysiologic vomiting in six, chronic epigastric pain in 17, gastritis in nine, peptic ulcer in five, psychophysiologic diarrhea in six, psychogenic megacolon in five and ulcerative colitis in one. The children were treated with psychotherapy alone, with an experimental drug opipramol (Ensidon·), or amitriptyline (Elavil··); or a combination of psychotherapy with either of these drugs. Therapy varied from approximately six months to two years with an average of about a year. Over-all satisfactory improvement was 43 per cent with psychotherapy alone, 75 per cent with chemotherapy alone, and when psychotherapy was combined with drug therapy the response was 54 per ·Geigy Pharmaceuticals, Ardsley, N. J. oOMerck Sharp and Dohme, West Point, Penn. 330

cent. The somewhat paradoxically superior influence of chemotherapy alone was considered to be due to the type of patients treated by this method. They were apparently more amenable to treatment due to lesser chronicity and lesser severity. Above all, however, it was seen that treatment was most successful in those patients who could be influenced directly by chemotherapy when the parental attitudes could be altered positively. This decreased those negative environmental factors which were responsible for the maladaptation in the first place. Strengthening the support needed for achievement of a proper emotional equilibrium appears to have resulted in improved defenses against the exogenous stresses. REl-'EREI'CES

1. Wolf, S. and Han', L. c., editors: Life Stress and Bodily Disease, Vol. 29, A. Res. Nervous and ~Iental Disorder, Pmc. Williams and Williams, Baltimore, 1950.

2. Cleghorn, R. A.: Thl' Hypothalamic-Endocrine System. Psycll()som ..'Iec/. 17:367, 1955. 3. ~IcLe
Plattsburgh Chikl Guidance Clinic Plattsburgh, New York Volume V.III