Psychiatry, psychotherapy and gastroenterology -- bringing it all together

'No entry', an invitation to intrude, or both? Reflections on a group of anorexic patients

This paper describes the twice-weekly psychoanalytic psychotherapy of a young woman who had undergone major bowel surgery in her early 20s, with no clear medical indication for the surgery. Whilst the concept of 'No Entry' described by Williams (, b) aptly describes many features of more 'typical' anorexic patients, this paper describes a particular group of anorexic patients, referred by their physicians for multiple medical procedures; and proposes there is a group of anorexic patients, repeatedly referred for medical investigations, into whom particular types of entries occur. These are entries into the body 'legitimized' as medical, with a trajectory towards multiple procedures, examinations and surgical operations. Other entries (outside the medical setting) may occur in a state of altered consciousness, under the influence of alcohol or drugs, such that any wish for intrusion is disowned and denied. In both sets of events, intrusion is both invited, and consciously denied. The case example illuminates some of these features, and aspects of the countertransference are also described. Attention is drawn to relevant research focusing on surgical intrusion. Finally, there is an exploration as to how such patients may invite intrusions into the body through surgery and medical procedures.

The use of Resolor (prucalopride) for chronic constipation in women

Chronic constipation is a common problem among women, is associated with anxiety and depression and can adversely affect quality of life (Mason et al, 2002). Chronic constipation is often unrelieved by simple laxatives, dietary manipulation or lifestyle modification, with other specialist treatment options being invasive and often not widely available. More recently attention has turned to newer prokinetic agents, such as prucalopride (Resolor®), which increase gut motility and intestinal transit, for the relief of chronic constipation. While these are not effective for everyone, there is evidence that prucalopride can increase bowel frequency, relieve bothersome symptoms associated with constipation and improve quality of life for women who have failed to achieve satisfactory relief from two other laxatives (National Institute for Health and Clinical Excellence).

Home parenteral nutrition and the psyche: psychological challenges for patient and family

The paper discusses the case histories of three patients who have faced the emotional implications of being initiated onto long-term parenteral nutrition (PN). In each case the patient's personal and family history, relationship to their illness and the presence or relative absence of resentments and grievances have influenced their ability to tolerate the training and the transition to home PN (HPN). In addition, the emotional importance of food and feeding from a developmental and social perspective is explored, together with the numerous psychological and social ‘losses’ experienced by all patients on PN and the adaptations required within the family setting. The ‘meaning’ of PN to the individual and the need for both internal and external support are identified and, based on clinical experience, a number of features are described that may be indicative of the relative abilities of different patients to cope with HPN. Finally, the role of a dedicated Psychological Medicine Unit closely allied to a nutrition service is discussed.

Influence of experimentally induced anxiety on gastric sensorimotor function in humans

BACKGROUND & AIMS

Unexplained dyspeptic symptoms are associated with changes in gastric sensorimotor function and several psychopathologic dimensions, including anxiety. It is unclear whether this reflects common predisposition or a causal relationship. The aim of this study was to investigate whether experimentally induced anxiety would alter gastric sensorimotor function in health.

METHODS

Fourteen subjects underwent a gastric barostat study to assess gastric sensitivity and accommodation. Eighteen subjects underwent a 10-minute satiety drinking test (30 mL/min) with registration of epigastric symptoms on a visual analogue scale (VAS) at 2-minute intervals. Emotional context was modulated for 10 minutes at the start of each experiment by combined projection of validated facial expressions and an audiotape recalling a neutral or an anxious autobiographical experience. Anxiety levels were assessed using a VAS and the Spielberger State-Trait Anxiety Inventory (STAI).

RESULTS

VAS and STAI scores confirmed efficacy of anxiety induction. During the anxiety condition, gastric compliance was significantly decreased (57 +/- 5 vs 40 +/- 5 mL/mm Hg; P < .01). Intraballoon pressures inducing discomfort during gastric distention were not altered, but the corresponding volume (630 +/- 47 vs 489 +/- 39 mL; P < .005) was significantly lower. Meal-induced relaxation was inhibited during the anxiety condition and this persisted for the 60-minute measurement (157 +/- 29 vs 100 +/- 24 mL; P < .05). During the satiety drinking test, the anxiety condition was associated with significantly higher scores for satiety, fullness, and bloating.

CONCLUSIONS

Experimentally induced anxiety alters gastric sensorimotor function, suggesting that psychological factors may play a causal role in the pathogenesis of some dyspeptic symptoms and mechanisms.

Central nervous system involvement in functional gastrointestinal disorders

Although functional gastrointestinal disorders (FGID) are common, their pathophysiology remains incompletely understood. It is generally accepted that dysfunction of the bidirectional pathways between the gastrointestinal tract and the central nervous system (the 'brain-gut axis') at any level can cause FGID symptoms. In this review article, we focus on the role of the central nervous system in the brain-gut axis. First, we describe the functional anatomy of the brain-gut axis. Second, we focus on the results from brain-imaging studies both in healthy volunteers and in FGID patients. These new investigational techniques made identification of brain regions critically involved in processing of visceral afferent information possible. Differences in central nervous system response to visceral stimuli between controls and FGID patients will be highlighted. Third, we will address the issue of high comorbidity with psychiatric disorders. Some hypotheses about common pathophysiological substrates will be discussed.