Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Psychosomatic Aspects of Gastrointestinal Disease F. Patrick Mckegney To cite this article: F. Patrick Mckegney (1975) Psychosomatic Aspects of Gastrointestinal Disease, Postgraduate Medicine, 57:1, 43-48, DOI: 10.1080/00325481.1975.11713941 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11713941
Published online: 07 Jul 2016.
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View related articles
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Date: 22 August 2017, At: 10:56
CO
s1der • What variables may negatively affect reliability of the data base obtained from the patient? • How significant are psychologic variables in the diagnosis and treatment of pancreatitis? • How can the physician best help the crock?
F. PATRICK McKEGNEY, MD
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
University of Vermont College of Medicine Burlington
Psychosomatic Aspects of Castrointestinal Disease A major problem in clinical gastroenterology is lack of knowledge as to what constitutes a data base that is adequate to exclude a diagnosis of organic disease and justify one of "functional" disease. This area deserves some consideration, particularly now as we embark on the development of standards of care. What diagnostic evaluation1s to be considered excessive and unnecessary, and under what circumstances? Clinical and chemical parameters for quantitating psychologic aspects of human behavior are becoming more standardized, and we may be in for some surprises as we delve deeper into the nature of psychic and somatic interactions, especially with regard to cause and effect.-AR
"Psychological" and "physical" cannot usefully be thought of as refemng to different kinds of states or events; rather they are names of different but parallel languages that may be used for describing exactly the same events. ... Mind-body dualism is co"ect; but the duality is in the languages used.... Cu"ent conceptual difficulties, leading to serious practical e"ors, result from the failure of physicians to recognize what they are doing. There is no special reason for them to stop using two languages, but it becomes important that they become aware that they are doing so.-David Graham1 It is in the context of David Graham's state-
Vol. 57 • No. 1 • January 1975 • POSTIIRADUATE MEDICINE
ment that a separate discussion of psychosomatic aspects of gastrointestinal disease is presented in this symposium. I have prefaced the discussion with this explanation because the word "psychosomatic" in the article title can, unfortunately, reinforce the age-old tendency of physicians to separate mind and body; to view psychologic and social aspects of health and illness as unrelated to biologic aspects of disease; and to compartmentalize data of each type, without real integration. In short, it may reinforce the concept of mind-body dualism that has led to serious conceptual and methodologic errors. Separation of the psychologic from the somatic has permitted the physician to ignore psychosocial data and interventions and to concentrate on the more easily defined data base obtained from laboratory and physical examinations. Data obtained by these methods are frequently inadequate for a satisfactory understanding of the patient's problems or for their resolution, but this has not been reflected in major changes in medical education or practice.2 •8 A conceptual framework and an overview of the integrated biologic and psychosocial aspects of disease are helpful. I 4 have presented these for gastrointestinal disturbances previously in this journal and will not restate them here. Self-test for this article appears on page 48.
43
Rather, this article will focus first on psychologic issues related to data-base reliability and the patient designated as a crock, two topics that are particularly relevant to disorders of the gastrointestinal tract. The specific syndromes of pancreatitis, pancreatic cancer, peptic ulcer, and inflammatory bowel disease will then be presented from a psychosocial viewpoint.
a very compliant patient, who may affirmatively answer leading questions about symptomatology without grasping the distinctions implied and assumed by the physician. A quite different source of data-base unreliability is exemplified by the patient who describes a large number of dramatic symptoms in graphic detail and in association with many other pieces of information. Sorting out the reliable data may be very aggravating to busy physicians, but they should curb their impatience and recognize the strong likelihood of a significant psychiatric problem, such as hypochondriasis or hysteria. The physician then should maintain special vigilance for signs of abnormal biologic functioning, in order to counter the natural tendency to dismiss the patient as only psychiatrically disturbed. It is useful to recall the axiom, "Crocks aren't immortal; they always die of something."
Data-Base Reliability
The Crock
F. PATRICK McKEGNEY
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Dr. McKegney is professor, department of psychiatry, University of Vermont College of Medicine, Burlington.
Gastrointestinal diseases, and symptoms referred to that system, are notoriously protean in their mode of expression. As a result, gastroenterologists must often make a special effort to evoke a precise, clear description of the patient's perceptions of sensations, symptom chronology, and relationship of symptoms to other phenomena, such as meals. Despite that extra effort, however, some sources of data-base unreliability may escape detection, and the physician's belief in the accuracy of the painstakingly gathered history may thus prove mistaken. One common source of error, especially in the older patient, is memory loss, caused by impaired brain function, that may not be grossly evident in an initial interview. A quick cognitive function examination, eliciting dates or facts that the physician can corroborate from other sources, can reveal this impairment early in the history-taking. Such a finding indicates the advisability of attenuating the search for historical data from the patient, gathering it later from other sources, and using the time spent with the patient to focus on present problems and to build rapport. Another set of factors affecting the reliability of the data base obtained from the patient includes low educational level, and language, social, racial, or ethnic differences between patient and physician. These factors may be obscured in
One derivation of this widely used, and abused, term for certain patients is that it is an acronym for the "chronically reappearing outpatient clinic kase." Patients who are thus labeled are at considerable health risk, since they usually alienate health care personnel and thus receive little attention to their psychologic or biologic needs. Further, the physician is usually unhappy about letting a patient provoke anger and about not alleviating the patient's complaints. Such patients require from the health care system a disproportionately large amount of time and energy, resources usually already in short supply. This heavy toll of unhappiness and waste indicates a need for more attention to this problem. There is probably little need to describe in detail the behavior of crocks. In brief, they have many somatic complaints, frequently referred to the gastrointestinal system,3 for which biologic abnormalities cannot be found. The symptoms shift over time, making priorities difficult to determine in terms of severity. The degree of incapacitation associated with the plethora of symptoms may be minimal. An outstanding feature of such patients is their demand for medical attention and their lack of response to any of the usual medical approaches to somatic symptoms. In fact, such patients often seem to get worse with diagnostic or treatment procedures. For example,
44
POSTGRADUATE MEDICINE • January 1975 • Vol. 57 • No. 1
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Pancreatitis and Pancreatic Cancer
they have adverse reactions to most medications and say, "I can't take pills" or "Everything works against me." Indeed, according to S. Weiner, MD (oral communication, September 1974), crocks can be understood as people with very low complaint thresholds who perceive and respond to sensory stimuli of which most individuals are fortunately unaware. Psychologically the crock designation usually fits the long-suffering, self-sacrificing personality type described by Kahana and Bebring.5 The patient often shows muted anger, particularly focused on unsatisfactory past medical care. The physician may find it difficult to get beyond somatic symptoms to gather data about the patient's life-style, work history, and interpersonal relationships. Such data usually show repeated real or perceived losses of persons and role satisfaction, often resulting in part from the patient's behavior. This alienation of others, including the physician, causes the patient to suffer and may satisfy a masochistic need for suffering as a substitute for love and dependency. While this theoretical formulation may appear irrelevant, even if true, it forms the basis of an important principle in the treatment of the crock. As Lipsett6 states: "The physician must somehow convey to the patient that he is more interested in maintaining the relationship than in curing symptoms. To become concerned with whether the symptoms improve or not is to perpetuate the patient's belief that the flow of affection is directly linked to symptoms and that what happens to the patient is more for the doctor's gratification (as it undoubtedly was for the patient's parents) than the patient's. While patients must be given credit for their ability to rise above hardship, for their dedication and self-sacrifice and for their strengths, they must not be promised cures or even improvement. Such an outcome is greatly feared by the patient, since it is equated with discharge from the clinic and therefore withdrawal of love. Some attempt is made to avoid this problem by allowing patients to decide for themselves whether they will come or not and how often. They respond positively to this approach and to urgings to fight their illness, to be a 'soldier,' to try to get along without medicine, etc. They even can be encouraged to 'be your · own doctor' provided visits continue and the patient is not discharged."
Both pancreatitis and pancreatic cancer are closely associated with psychologic problems, but the problems are of quite different types. Psychologic impairments in patients with either disease can affect the reliability of the data base obtained from them. Patients with pancreatitis usually have a history of heavy and chronic alcohol intake, although they may deny it or the physician may avoid it. Heavy drinking should be dealt with as a distinct psychosocial problem leading to a full investigation of maladaptive consequences of the patient's drinking and of factors contributing to alcoholic dependence. Treatment plans for this problem must include patient education, motivation to alter drinking habits, and mobilization of resources to assist the patient in this task, including frequent and open discussion with the physician. In addition, abstinence from alcohol, with or without hospitalization, will lead to a withdrawal syndrome varying in severity from mild agitation to full-blown delirium tremens. The latter obviously has serious implications for patient morbidity or mortality, adding to the risk of the pancreatitis. In a series of patients hospitalized for pancreatitis, Schuster and Iber1 found that the incidence of behavioral disturbances of psychotic proportions exceeded 50%. In this type of toxic psychosis, the biochemical concomitants of the pancreatitis affect brain function and alter the patient's state of consciousness.8 The delirium can be managed by a variety of means,9 but improvement depends on reversing the pathophysiology secondary to the pancreatitis. Patients with pancreatic carcinoma also have a high incidence of associated psychiatric symptoms. These are, however, quite different from those in patients with pancreatitis. Fras and colleagues10 found that 76% of a group of 46 consecutive patients with pancreatic carcinoma showed depression, anxiety, or premonition of serious illness. These authors stated, "Since these psychiatric symptoms appeared before any other symptoms in nearly half of the patients, these symptoms should be regarded as an aid in the diagnosis of carcinoma of the pancreas." The incidence of these psychiatric symptoms in patients with pancreatic cancer is much higher than in other groups of cancer patients or in
Vol. 57 • No. 1 • January 1975 • POSTGRADUATE MEDICINE
45
TABLE 1. INCIDENCE OF PSYCHOLOGIC FACTORS IN INFLAMMATORY BOWEL DISEASE
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Factor
Ulcerative Colitis
Crohn's Disease
(%)
(%)
Psychiatric diagnoses
38
47
Other measures of emotional disturbance
33
47
Major life events associated with onset of disease
86
68
noncancer patient control groups. However, the mechanisms of the association are not clearly understood. No toxic factors have been demonstrated in pancreatic carcinoma patients to explain the early psychiatric symptoms. The depressive syndrome in such patients can usually be distinguished from that found in involutional depressive reactions, which has its highest incidence in the same age group, ie, 50 to 70 years. Compared to those with the latter syndrome, patients with pancreatic cancer had only mild to moderate depression with no delusional thinking or prominent feelings of guilt or worthlessness, no restlessness or agitation, little suicidal ideation, insomnia related to intractable pain, and a clear sensorium. 10 Peptic Ulcer Disease
Biologic, psychologic, and environmental factors interact dynamically in the development of peptic ulcer disease. No one factor is sufficient in itself to cause the disease; all need to be present to some degree.U The biologic factor most clearly related to peptic ulcer is the gastric acid secretory capacity, as reflected in the levels of serum or urine pepsinogen. This genetically determined capacity may be considered a predisposing factor, although it may also indirectly influence psychologic and even social-environmental factors. 3 Other biologic mechanisms contributing to ulcer disease, such as the relative absence of protective mucus, may be associated with blood group 0, but these have not been demonstrated so clearly.U Certain psychologic factors have proved quite reliable in predicting which individuals have
46
gastric acid hypersecretion and are thus at risk for the development of peptic ulcer disease. These factors include a marked dependency in relationships to other persons, compliance, and passivity. 12 However, these individuals may manifest the opposite behavior and appear to be hard-driving, hyperindependent, and aggressive. Environmental factors which seem necessary for the development of an ulcer are those "which induce a mobilization of unconscious oral-receptive and incorporative wishes, or serve as a threat to dependent relationships." 11 Such events have been shown to lead to an increase in the rate of pepsinogen secretion. In people with a high secretory capacity and a psychologic makeup that sensitizes them to such environmental events, this increase in secretion at time of stress could tip the biologic balance to produce peptic ulceration. Whether the interaction of these factors actually produces somatic disease seems to depend upon the degree of success achieved in coping with stress. W einer and colleagues12 were able to predict prospectively, with a high degree of accuracy, those persons in the biologically and psychologically predisposed group in whom ulcer disease actually developed; their prediction was based on these individuals' higher levels of anxiety and overt conflict. In summary, the development of an ulcer will depend on an individual's ability to successfully cope with a certain set of life events, given a psychologic sensitivity to that type of stress and a biologic predisposition to hypersecretion. General treatment principles have been dealt with elsewhere.3 The basic tenet of therapy remains "change all that can be changed." Specific goals are to therapeutically manipulate the environment to lessen the stress on the individual, help the person to improve his mode of coping with the life situation, modify the psychologic sensitivity of the individual to such stresses, and influence the biologic processes in the appropriate directions. The success of this combined biologic-psychologic approach can be predicted to a degree. The characteristics associated with poor response to treatment are not specific to peptic ulcer patients but probably correlate with poor response to treatment of any chronic or recur-
POSTGRADUATE MEDICINE • January 1975 • Vol. 57 • No. 1
ring disease, since they reflect general adaptational, or coping, capacities. These characteristics include poor employment record, low job satisfaction, low income, poor socialization and interpersonal relationships, low self-esteem, and apprehension about present and future status. 13
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Inflammatory Bowel Disease
Ulcerative colitis and Crohn's disease comprise the major forms of inflammatory bowel disease. Recent biologic and psychologic studies tend to view these two syndromes as being on a continuum. From the psychologic standpoint, patients with either disease reflect certain similar characteristics.14 There is a high correlation between the severity of the physical disease and the degree of emotional disturbance (table 1). In severe, acute phases of either illness, a toxic state may cause a delirium and associated behavior abnormalities very similar to those found in severe pancreatitis. The high correlation between biologic and psychologic parameters has several implications. Severe biologic disease should alert the responsible physician to the likelihood of a concomitant severe psychologic problem, indicating the need for psychiatric consultation early in the diagnostic and treatment program. The referral for psychiatric consultation will be seen as much more rational and be better accepted by the patient if, from the outset of contact, the physician has discussed with the patient psychologic factors and the possibility that these may
need attention. Life events and the patient's coping abilities must be given as much continuing emphasis by the physician as are the biologic parameters. Patients with more severe inflammatory bowel disease require close coordination between the physician and others who are significant in the patient's life, including an involved psychiatrist. Summary
Gastrointestinal diseases are notoriously protean in their modes of expression. The patient's description of symptoms is particularly important, but psychologic, physiologic, and social factors can cause data-base unreliability. Many of the patients termed crocks have symptoms referable to the gastrointestinal system, and they are at considerable health risk, since they usually alienate health care personnel. Patients with pancreatitis usually have a history of heavy alcohol intake which also needs treatment. Behavioral disturbances are related to toxic psychosis. Pancreatic carcinoma has a higher incidence of associated psychiatric symptoms than other types of cancer. Biologic, psychologic, and environmental factors all interact dynamically to cause peptic ulcer disease. There is a high correlation between the severity of inflammatory bowel disease and degree of emotional disturbance. For ReadySource on gastrointestinal disorders, see page 185.
REFERENCES 1. Graham DT: Health, disease, and the mind-body problem: Linguistic parallelism. Psychosom Med 29:52, 1967 2. Payson HE, Gaenslen EC Jr, Stargardter FL: Time study of an internship on a university medical service. N Engl] Med 264:439, 1961 3. Payson HE, Barchas ]D: A time study of medical teaching rounds. N Engl] Med 273:146, 1965 4. McKegney FP: Psychosomatic gastrointestinal disturbances: A multifactor, interactional concept. Postgrad Med 47:109, May 1970 5. Kahana RJ, Bebring GL: Personality types in medical management. In Zinberg NE (Editor) : Psychiatry and Medical Practice in the General Hospital. New York, International Universities Press, 1964 6. Lipsett DR: Medical and psychological characteristics of "crocks." Psychiatry Med 1:15, 1970 7. Schuster MM, lber FL: Psychosis with pancreatitis: A frequent occurrence infrequently recognized. Arch Intern Med 116:228, 1965 8. Lipowski Z]: Delirium, clouding of consciousness
and confusion. J Nerv Ment Dis 145:227, 1967 9. Senay EC, McKegney FP: Common psychiatric emergencies in the- general hospital. GP 37:102, 1968 10. Fras I, Litin EM, Pearson JS: Comparison of psychiatric symptoms in carcinoma of the pancreas with those in some other intra-abdominal neoplasms. Am J Psychiatry 123:1553, 1967 11. Mirsky lA: Physiologic, psychologic and social determinants in the etiology of duodenal ulcer. Am ] Dig Dis 3:285, 1958 12. Weiner H, Thaler M, Reiser MF, et al: Etiology of duodenal ulcer. I. Relation of specific psychological characteristics to rate of gastric secre-tion. Psychosom Med 18:2, 1957 13. Pascal GR, Thoroughman JC: Psychological studies of surgical intractability in duodenal ulcer patients. Psychosomatics 8:11, 1967 14. McKegney FP, Gordon RO, Levine SM: A psychosomatic comparison of patients with ulcerative colitis and Crohn's disease. Psychosom Med 32:153, 1970
Vol. 57 • No. 1 • January 1975 • POSTGRADUATE MEDICINE
47
se --test
answes
Select the best answer for each of the following questions.
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
1. Which of the following factors may negatively affect reliability of the data base obtained from the patient? a. Organic brain syndrome c. Physician-patient educational or social differences b. Hypochondriasis or hysteria d. All of the above 2. Which of the following phrases is a. Considerable health risk b. Masochistic need
not associated with the crock?
d
c
c. High complaint threshold d. Multiple vague complaints
3. What are the major psychiatric problems associated with pancreatitis? a. Toxic psychosis or delirium c. Depression and anxiety b. Chronic alcoholism d. Both a and b
d
4. What biologic predisposition to ulcer disease has been correlated with psychologic characteristics? a. Blood type 0 c. Relative absence of protective b. Increased pepsinogen mucus secretion d. Both a and b
b
5. What psychiatric symptoms are found in patients with pancreatic cancer? c. High suicidal tendency a. Mild to moderate depression d. Both a and b b. Premonition of serious illness
d
6. What is the association between the severity of inflammatory bowel disease and psychiatric disturbance? a. Highly significant positive correlation b. Moderately significant positive correlation c. Low significant positive correlation d. No statistically significant positive correlation
a
Read the case study below and answer the questions. A 48-year-old divorced waitress has sudden onset of diarrhea and sharp abdominal pains. She was once told she had "colitis" and was treated with a "sulfa" pill. Physical examination reveals generalized abdominal tenderness and hyperactive bowel sounds. a. What studies would you order?
a. Barium enema study, upper gastrointestinal ser1es and sma 11-bowel follow-through, proctoscopy b. Elicit social habits history
and
personal
c. Perhaps belladonna derivatives; psychiatric counseling, preferably by you; reassurance; provision for follow-up
b. Results of a barium enemia study, upper gastrointestinal series with small-bowel follow-through, and proctoscopy were normal. What is the next probable step? c. Further history reveals heavy alcohol intake and trouble with the ex-husband. What therapy would you recommend?
48
POSTGRADUATE MEDICINE • January 1975 • Vol. 57 • No. 1
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Psychosomatic Aspects of Gastrointestinal Disease F. Patrick Mckegney To cite this article: F. Patrick Mckegney (1975) Psychosomatic Aspects of Gastrointestinal Disease, Postgraduate Medicine, 57:1, 43-48, DOI: 10.1080/00325481.1975.11713941 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11713941
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 22 August 2017, At: 10:56
CO
s1der • What variables may negatively affect reliability of the data base obtained from the patient? • How significant are psychologic variables in the diagnosis and treatment of pancreatitis? • How can the physician best help the crock?
F. PATRICK McKEGNEY, MD
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
University of Vermont College of Medicine Burlington
Psychosomatic Aspects of Castrointestinal Disease A major problem in clinical gastroenterology is lack of knowledge as to what constitutes a data base that is adequate to exclude a diagnosis of organic disease and justify one of "functional" disease. This area deserves some consideration, particularly now as we embark on the development of standards of care. What diagnostic evaluation1s to be considered excessive and unnecessary, and under what circumstances? Clinical and chemical parameters for quantitating psychologic aspects of human behavior are becoming more standardized, and we may be in for some surprises as we delve deeper into the nature of psychic and somatic interactions, especially with regard to cause and effect.-AR
"Psychological" and "physical" cannot usefully be thought of as refemng to different kinds of states or events; rather they are names of different but parallel languages that may be used for describing exactly the same events. ... Mind-body dualism is co"ect; but the duality is in the languages used.... Cu"ent conceptual difficulties, leading to serious practical e"ors, result from the failure of physicians to recognize what they are doing. There is no special reason for them to stop using two languages, but it becomes important that they become aware that they are doing so.-David Graham1 It is in the context of David Graham's state-
Vol. 57 • No. 1 • January 1975 • POSTIIRADUATE MEDICINE
ment that a separate discussion of psychosomatic aspects of gastrointestinal disease is presented in this symposium. I have prefaced the discussion with this explanation because the word "psychosomatic" in the article title can, unfortunately, reinforce the age-old tendency of physicians to separate mind and body; to view psychologic and social aspects of health and illness as unrelated to biologic aspects of disease; and to compartmentalize data of each type, without real integration. In short, it may reinforce the concept of mind-body dualism that has led to serious conceptual and methodologic errors. Separation of the psychologic from the somatic has permitted the physician to ignore psychosocial data and interventions and to concentrate on the more easily defined data base obtained from laboratory and physical examinations. Data obtained by these methods are frequently inadequate for a satisfactory understanding of the patient's problems or for their resolution, but this has not been reflected in major changes in medical education or practice.2 •8 A conceptual framework and an overview of the integrated biologic and psychosocial aspects of disease are helpful. I 4 have presented these for gastrointestinal disturbances previously in this journal and will not restate them here. Self-test for this article appears on page 48.
43
Rather, this article will focus first on psychologic issues related to data-base reliability and the patient designated as a crock, two topics that are particularly relevant to disorders of the gastrointestinal tract. The specific syndromes of pancreatitis, pancreatic cancer, peptic ulcer, and inflammatory bowel disease will then be presented from a psychosocial viewpoint.
a very compliant patient, who may affirmatively answer leading questions about symptomatology without grasping the distinctions implied and assumed by the physician. A quite different source of data-base unreliability is exemplified by the patient who describes a large number of dramatic symptoms in graphic detail and in association with many other pieces of information. Sorting out the reliable data may be very aggravating to busy physicians, but they should curb their impatience and recognize the strong likelihood of a significant psychiatric problem, such as hypochondriasis or hysteria. The physician then should maintain special vigilance for signs of abnormal biologic functioning, in order to counter the natural tendency to dismiss the patient as only psychiatrically disturbed. It is useful to recall the axiom, "Crocks aren't immortal; they always die of something."
Data-Base Reliability
The Crock
F. PATRICK McKEGNEY
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Dr. McKegney is professor, department of psychiatry, University of Vermont College of Medicine, Burlington.
Gastrointestinal diseases, and symptoms referred to that system, are notoriously protean in their mode of expression. As a result, gastroenterologists must often make a special effort to evoke a precise, clear description of the patient's perceptions of sensations, symptom chronology, and relationship of symptoms to other phenomena, such as meals. Despite that extra effort, however, some sources of data-base unreliability may escape detection, and the physician's belief in the accuracy of the painstakingly gathered history may thus prove mistaken. One common source of error, especially in the older patient, is memory loss, caused by impaired brain function, that may not be grossly evident in an initial interview. A quick cognitive function examination, eliciting dates or facts that the physician can corroborate from other sources, can reveal this impairment early in the history-taking. Such a finding indicates the advisability of attenuating the search for historical data from the patient, gathering it later from other sources, and using the time spent with the patient to focus on present problems and to build rapport. Another set of factors affecting the reliability of the data base obtained from the patient includes low educational level, and language, social, racial, or ethnic differences between patient and physician. These factors may be obscured in
One derivation of this widely used, and abused, term for certain patients is that it is an acronym for the "chronically reappearing outpatient clinic kase." Patients who are thus labeled are at considerable health risk, since they usually alienate health care personnel and thus receive little attention to their psychologic or biologic needs. Further, the physician is usually unhappy about letting a patient provoke anger and about not alleviating the patient's complaints. Such patients require from the health care system a disproportionately large amount of time and energy, resources usually already in short supply. This heavy toll of unhappiness and waste indicates a need for more attention to this problem. There is probably little need to describe in detail the behavior of crocks. In brief, they have many somatic complaints, frequently referred to the gastrointestinal system,3 for which biologic abnormalities cannot be found. The symptoms shift over time, making priorities difficult to determine in terms of severity. The degree of incapacitation associated with the plethora of symptoms may be minimal. An outstanding feature of such patients is their demand for medical attention and their lack of response to any of the usual medical approaches to somatic symptoms. In fact, such patients often seem to get worse with diagnostic or treatment procedures. For example,
44
POSTGRADUATE MEDICINE • January 1975 • Vol. 57 • No. 1
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Pancreatitis and Pancreatic Cancer
they have adverse reactions to most medications and say, "I can't take pills" or "Everything works against me." Indeed, according to S. Weiner, MD (oral communication, September 1974), crocks can be understood as people with very low complaint thresholds who perceive and respond to sensory stimuli of which most individuals are fortunately unaware. Psychologically the crock designation usually fits the long-suffering, self-sacrificing personality type described by Kahana and Bebring.5 The patient often shows muted anger, particularly focused on unsatisfactory past medical care. The physician may find it difficult to get beyond somatic symptoms to gather data about the patient's life-style, work history, and interpersonal relationships. Such data usually show repeated real or perceived losses of persons and role satisfaction, often resulting in part from the patient's behavior. This alienation of others, including the physician, causes the patient to suffer and may satisfy a masochistic need for suffering as a substitute for love and dependency. While this theoretical formulation may appear irrelevant, even if true, it forms the basis of an important principle in the treatment of the crock. As Lipsett6 states: "The physician must somehow convey to the patient that he is more interested in maintaining the relationship than in curing symptoms. To become concerned with whether the symptoms improve or not is to perpetuate the patient's belief that the flow of affection is directly linked to symptoms and that what happens to the patient is more for the doctor's gratification (as it undoubtedly was for the patient's parents) than the patient's. While patients must be given credit for their ability to rise above hardship, for their dedication and self-sacrifice and for their strengths, they must not be promised cures or even improvement. Such an outcome is greatly feared by the patient, since it is equated with discharge from the clinic and therefore withdrawal of love. Some attempt is made to avoid this problem by allowing patients to decide for themselves whether they will come or not and how often. They respond positively to this approach and to urgings to fight their illness, to be a 'soldier,' to try to get along without medicine, etc. They even can be encouraged to 'be your · own doctor' provided visits continue and the patient is not discharged."
Both pancreatitis and pancreatic cancer are closely associated with psychologic problems, but the problems are of quite different types. Psychologic impairments in patients with either disease can affect the reliability of the data base obtained from them. Patients with pancreatitis usually have a history of heavy and chronic alcohol intake, although they may deny it or the physician may avoid it. Heavy drinking should be dealt with as a distinct psychosocial problem leading to a full investigation of maladaptive consequences of the patient's drinking and of factors contributing to alcoholic dependence. Treatment plans for this problem must include patient education, motivation to alter drinking habits, and mobilization of resources to assist the patient in this task, including frequent and open discussion with the physician. In addition, abstinence from alcohol, with or without hospitalization, will lead to a withdrawal syndrome varying in severity from mild agitation to full-blown delirium tremens. The latter obviously has serious implications for patient morbidity or mortality, adding to the risk of the pancreatitis. In a series of patients hospitalized for pancreatitis, Schuster and Iber1 found that the incidence of behavioral disturbances of psychotic proportions exceeded 50%. In this type of toxic psychosis, the biochemical concomitants of the pancreatitis affect brain function and alter the patient's state of consciousness.8 The delirium can be managed by a variety of means,9 but improvement depends on reversing the pathophysiology secondary to the pancreatitis. Patients with pancreatic carcinoma also have a high incidence of associated psychiatric symptoms. These are, however, quite different from those in patients with pancreatitis. Fras and colleagues10 found that 76% of a group of 46 consecutive patients with pancreatic carcinoma showed depression, anxiety, or premonition of serious illness. These authors stated, "Since these psychiatric symptoms appeared before any other symptoms in nearly half of the patients, these symptoms should be regarded as an aid in the diagnosis of carcinoma of the pancreas." The incidence of these psychiatric symptoms in patients with pancreatic cancer is much higher than in other groups of cancer patients or in
Vol. 57 • No. 1 • January 1975 • POSTGRADUATE MEDICINE
45
TABLE 1. INCIDENCE OF PSYCHOLOGIC FACTORS IN INFLAMMATORY BOWEL DISEASE
Downloaded by [Australian Catholic University] at 10:56 22 August 2017
Factor
Ulcerative Colitis
Crohn's Disease
(%)
(%)
Psychiatric diagnoses
38
47
Other measures of emotional disturbance
33
47
Major life events associated with onset of disease
86
68
noncancer patient control groups. However, the mechanisms of the association are not clearly understood. No toxic factors have been demonstrated in pancreatic carcinoma patients to explain the early psychiatric symptoms. The depressive syndrome in such patients can usually be distinguished from that found in involutional depressive reactions, which has its highest incidence in the same age group, ie, 50 to 70 years. Compared to those with the latter syndrome, patients with pancreatic cancer had only mild to moderate depression with no delusional thinking or prominent feelings of guilt or worthlessness, no restlessness or agitation, little suicidal ideation, insomnia related to intractable pain, and a clear sensorium. 10 Peptic Ulcer Disease
Biologic, psychologic, and environmental factors interact dynamically in the development of peptic ulcer disease. No one factor is sufficient in itself to cause the disease; all need to be present to some degree.U The biologic factor most clearly related to peptic ulcer is the gastric acid secretory capacity, as reflected in the levels of serum or urine pepsinogen. This genetically determined capacity may be considered a predisposing factor, although it may also indirectly influence psychologic and even social-environmental factors. 3 Other biologic mechanisms contributing to ulcer disease, such as the relative absence of protective mucus, may be associated with blood group 0, but these have not been demonstrated so clearly.U Certain psychologic factors have proved quite reliable in predicting which individuals have
46
gastric acid hypersecretion and are thus at risk for the development of peptic ulcer disease. These factors include a marked dependency in relationships to other persons, compliance, and passivity. 12 However, these individuals may manifest the opposite behavior and appear to be hard-driving, hyperindependent, and aggressive. Environmental factors which seem necessary for the development of an ulcer are those "which induce a mobilization of unconscious oral-receptive and incorporative wishes, or serve as a threat to dependent relationships." 11 Such events have been shown to lead to an increase in the rate of pepsinogen secretion. In people with a high secretory capacity and a psychologic makeup that sensitizes them to such environmental events, this increase in secretion at time of stress could tip the biologic balance to produce peptic ulceration. Whether the interaction of these factors actually produces somatic disease seems to depend upon the degree of success achieved in coping with stress. W einer and colleagues12 were able to predict prospectively, with a high degree of accuracy, those persons in the biologically and psychologically predisposed group in whom ulcer disease actually developed; their prediction was based on these individuals' higher levels of anxiety and overt conflict. In summary, the development of an ulcer will depend on an individual's ability to successfully cope with a certain set of life events, given a psychologic sensitivity to that type of stress and a biologic predisposition to hypersecretion. General treatment principles have been dealt with elsewhere.3 The basic tenet of therapy remains "change all that can be changed." Specific goals are to therapeutically manipulate the environment to lessen the stress on the individual, help the person to improve his mode of coping with the life situation, modify the psychologic sensitivity of the individual to such stresses, and influence the biologic processes in the appropriate directions. The success of this combined biologic-psychologic approach can be predicted to a degree. The characteristics associated with poor response to treatment are not specific to peptic ulcer patients but probably correlate with poor response to treatment of any chronic or recur-
POSTGRADUATE MEDICINE • January 1975 • Vol. 57 • No. 1
ring disease, since they reflect general adaptational, or coping, capacities. These characteristics include poor employment record, low job satisfaction, low income, poor socialization and interpersonal relationships, low self-esteem, and apprehension about present and future status. 13
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Inflammatory Bowel Disease
Ulcerative colitis and Crohn's disease comprise the major forms of inflammatory bowel disease. Recent biologic and psychologic studies tend to view these two syndromes as being on a continuum. From the psychologic standpoint, patients with either disease reflect certain similar characteristics.14 There is a high correlation between the severity of the physical disease and the degree of emotional disturbance (table 1). In severe, acute phases of either illness, a toxic state may cause a delirium and associated behavior abnormalities very similar to those found in severe pancreatitis. The high correlation between biologic and psychologic parameters has several implications. Severe biologic disease should alert the responsible physician to the likelihood of a concomitant severe psychologic problem, indicating the need for psychiatric consultation early in the diagnostic and treatment program. The referral for psychiatric consultation will be seen as much more rational and be better accepted by the patient if, from the outset of contact, the physician has discussed with the patient psychologic factors and the possibility that these may
need attention. Life events and the patient's coping abilities must be given as much continuing emphasis by the physician as are the biologic parameters. Patients with more severe inflammatory bowel disease require close coordination between the physician and others who are significant in the patient's life, including an involved psychiatrist. Summary
Gastrointestinal diseases are notoriously protean in their modes of expression. The patient's description of symptoms is particularly important, but psychologic, physiologic, and social factors can cause data-base unreliability. Many of the patients termed crocks have symptoms referable to the gastrointestinal system, and they are at considerable health risk, since they usually alienate health care personnel. Patients with pancreatitis usually have a history of heavy alcohol intake which also needs treatment. Behavioral disturbances are related to toxic psychosis. Pancreatic carcinoma has a higher incidence of associated psychiatric symptoms than other types of cancer. Biologic, psychologic, and environmental factors all interact dynamically to cause peptic ulcer disease. There is a high correlation between the severity of inflammatory bowel disease and degree of emotional disturbance. For ReadySource on gastrointestinal disorders, see page 185.
REFERENCES 1. Graham DT: Health, disease, and the mind-body problem: Linguistic parallelism. Psychosom Med 29:52, 1967 2. Payson HE, Gaenslen EC Jr, Stargardter FL: Time study of an internship on a university medical service. N Engl] Med 264:439, 1961 3. Payson HE, Barchas ]D: A time study of medical teaching rounds. N Engl] Med 273:146, 1965 4. McKegney FP: Psychosomatic gastrointestinal disturbances: A multifactor, interactional concept. Postgrad Med 47:109, May 1970 5. Kahana RJ, Bebring GL: Personality types in medical management. In Zinberg NE (Editor) : Psychiatry and Medical Practice in the General Hospital. New York, International Universities Press, 1964 6. Lipsett DR: Medical and psychological characteristics of "crocks." Psychiatry Med 1:15, 1970 7. Schuster MM, lber FL: Psychosis with pancreatitis: A frequent occurrence infrequently recognized. Arch Intern Med 116:228, 1965 8. Lipowski Z]: Delirium, clouding of consciousness
and confusion. J Nerv Ment Dis 145:227, 1967 9. Senay EC, McKegney FP: Common psychiatric emergencies in the- general hospital. GP 37:102, 1968 10. Fras I, Litin EM, Pearson JS: Comparison of psychiatric symptoms in carcinoma of the pancreas with those in some other intra-abdominal neoplasms. Am J Psychiatry 123:1553, 1967 11. Mirsky lA: Physiologic, psychologic and social determinants in the etiology of duodenal ulcer. Am ] Dig Dis 3:285, 1958 12. Weiner H, Thaler M, Reiser MF, et al: Etiology of duodenal ulcer. I. Relation of specific psychological characteristics to rate of gastric secre-tion. Psychosom Med 18:2, 1957 13. Pascal GR, Thoroughman JC: Psychological studies of surgical intractability in duodenal ulcer patients. Psychosomatics 8:11, 1967 14. McKegney FP, Gordon RO, Levine SM: A psychosomatic comparison of patients with ulcerative colitis and Crohn's disease. Psychosom Med 32:153, 1970
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47
se --test
answes
Select the best answer for each of the following questions.
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1. Which of the following factors may negatively affect reliability of the data base obtained from the patient? a. Organic brain syndrome c. Physician-patient educational or social differences b. Hypochondriasis or hysteria d. All of the above 2. Which of the following phrases is a. Considerable health risk b. Masochistic need
not associated with the crock?
d
c
c. High complaint threshold d. Multiple vague complaints
3. What are the major psychiatric problems associated with pancreatitis? a. Toxic psychosis or delirium c. Depression and anxiety b. Chronic alcoholism d. Both a and b
d
4. What biologic predisposition to ulcer disease has been correlated with psychologic characteristics? a. Blood type 0 c. Relative absence of protective b. Increased pepsinogen mucus secretion d. Both a and b
b
5. What psychiatric symptoms are found in patients with pancreatic cancer? c. High suicidal tendency a. Mild to moderate depression d. Both a and b b. Premonition of serious illness
d
6. What is the association between the severity of inflammatory bowel disease and psychiatric disturbance? a. Highly significant positive correlation b. Moderately significant positive correlation c. Low significant positive correlation d. No statistically significant positive correlation
a
Read the case study below and answer the questions. A 48-year-old divorced waitress has sudden onset of diarrhea and sharp abdominal pains. She was once told she had "colitis" and was treated with a "sulfa" pill. Physical examination reveals generalized abdominal tenderness and hyperactive bowel sounds. a. What studies would you order?
a. Barium enema study, upper gastrointestinal ser1es and sma 11-bowel follow-through, proctoscopy b. Elicit social habits history
and
personal
c. Perhaps belladonna derivatives; psychiatric counseling, preferably by you; reassurance; provision for follow-up
b. Results of a barium enemia study, upper gastrointestinal series with small-bowel follow-through, and proctoscopy were normal. What is the next probable step? c. Further history reveals heavy alcohol intake and trouble with the ex-husband. What therapy would you recommend?
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