According to ICD-10, in this disor der, symptoms are presented by the patient as if they were due to a physical disorder of an organ system that is pre-dominantly under autonomic control, e.g. heart and cardio vas cular system (such as palpitations), upper gastro intestinal tract (such as aerophagy, hiccough), lower gastrointestinal tract (such as fl atulence, irritable bowel), respiratory system (such as hyperventi la tion), genitourinary system (such as dysuria), or other organ systems.
There is preoccupation with, and distress regard-ing, the possibility of a serious (but often unspecifi ed) disorder of the particular organ system. Physical examination and investiga tions do not however show presence of any signifi cant abnormality. The pre-occupation persists des pite repeated assuran ces and explanations.
Treatment
The treatment consists of:
1. Supportive psychotherapy.
2. Drug treatment: The symptoms of anxiety and/or depression usually respond to short-term use of benzodiazepines and antidepres sants.
Some other common disorders are described in some detail below:
Hyperventilation Syndrome (HVS)
This is a very common clinical syndrome which is often missed, particularly when it does not present in its full blown form. The syndrome is characterised by a
‘habit’ of hyperventilation which becomes particularly marked in the pre sence of psychosocial stress, or any emotional upheaval.
In its mild form, it is characterised by exces sive fatigue, chest pain, headache, palpita tions, sweating and a feeling of ‘lightheaded ness’. In severe hyper-ventilation syndrome, carpopaedal spasm (tetany), paraesthesias and loss of consciousness may occur.
These symptoms are produced by hypo capnia (or a decrease in arterial pCO2). The sequence of events in hyperventilation syndrome is explained in Figure 8.3.
The diagnosis is usually easy, if the possi bility of hyperventilation is remembered. Apart from the clinical his tory and presence of frequent ‘sighing’
during the interview, a simple test would demonstrate the symptomatology. The patient is asked to breathe rapidly and deeply for 2-3 minutes. This pro duces the classical physical symptoms. If car ried on longer, tetany and unconsciousness would result; therefore, due care should be undertaken in performing this test.
Treatment
1. Relaxation techniques: Jacobson’s progres sive muscular relaxation, autohypnosis or hypno sis, yoga, transcendental meditation (TM), and/or biofeedback.
2. Teaching relaxed breathing techniques, which include:
i. Breathing more from the abdomen, thus avoid-ing the use of accessory muscles of expiration.
ii. Slow respiration with passive expiration, with-out muscular effort.
iii. A short rest cycle to be voluntarily intro duced after each respiratory cycle.
3. Treatment of underlying anxiety or depres sion, if present, with antidepressants and/or short-term benzodiazepines.
4. Breathing-in-bag technique: The aim of this technique is to have the patient re-breathe the expired air. This prevents the decrease in pCO2 which causes physical symptoms, or causes an increase in pCO2 where physical symp toms have already developed. Re-brea thing in a paper bag, which is carried by the patient, quickly reverts the symptoms. It is really important to emphasise a safe use of the bag, to prevent the possibility of suffo cation. There is some recent evidence doubt-ing the effi cacy of this approach.
Irritable Bowel Syndrome (IBS)
This is a common syndrome, often known by a large variety of names, such as spastic colitis, irritable
Fig. 8.3: Physiology of Hyperventilation Syndrome
colon syndrome, nervous diarrhoea, mucus colitis, and colon neurosis.
The principal abnormality in IBS is a distur bance of bowel mobility, which is modifi ed by psychosocial factors. The patients usually pre sent with one or more of the following symptoms:
1. Abdominal pain, discomfort or cramps.
2. Alteration of bowel habits (diarrhoea or constipa-tion).
3. A sensation of incomplete evacuation.
Quite often, all three features (abdominal pain and diarrhoea alternating with consti pation) are present together; also associated is fl atulence. The patients often describe their stools in a dramatic manner.
It is a fairly common disorder occurring in nearly 40% of all patients attending a gastro enterology (GE) clinic. Although females more frequently have IBS in America, in India males are more often affected. It is more or less a stable disorder with frequent exacerba-tions.
The typical mode of onset or exacerbation is with occurrence of a psychosocial stressor or emotional upheaval. Physiologically, there are two changes pos-sible in the bowel motility.
1. Hypomotility, which is often associated with pain-less diarrhoea.
2. Hypermotility, which presents clinically as painful constipation or rarely painful diarrhoea.
Treatment
1. A stable and trustful doctor-patient relation ship.
2. Supportive psychotherapy is best carried out in medical or GE clinic by the treating physi cian.
These patients often resent psychiatric referrals.
3. Identifi cation of current life stressors, environ-mental manipulation, and learning of coping skills aimed at dealing with stressors are very helpful.
4. Anti-anxiety and antidepressant medication may be helpful at times. At other times, they just act like placebos.
5. Symptomatic management is often unsuc cess ful.
However, prokinetic agents (e.g. cisa pride) may
sometimes be useful. A trial of fi bre (wheat bran, psyllium, methyl cellulose) is reasonable in some patients with irritable bowel syndrome.
Premenstrual Syndrome
Premenstrual syndrome or premenstrual tension (PMT—as it has been commonly called) is charac-terised by a variety of physical, psychological and behavioural symptoms occurring in the second half of menstrual cycle. Typically, the symptoms start after a few days of ovulation, reach a peak about 4-5 days before menstrua tion and disappear usually around menstrua tion. The period between menstruation and next ovulation is normal.
The syndrome is characterised by feelings of irritability, depression, crying spells, restlessness and anxiety. These are associated with changes in appetite, signs and symptoms of water retention (such as pedal oedema, weight gain, swelling of breasts, a sense of bloating of abdomen), gastro enterological changes, headache and fatigue.
The aetiology is probably multifactorial. The biological factors include faulty luteinisation, excess of oestrogens, and progesterone defi ciency. The psy-chosocial factors encompass educa tion, expectations and attitudes towards menstruation and femininity (‘tension’ about menstruation).
Treatment
1. The treatment of water retention can be by diu-retics, and restricting the fl uid intake. Thiazide diuretics are often prescribed but spironolactone (an aldosterone anta gonist) is probably superior.
2. Psychotherapy may be helpful in some cases where confl icts regarding mens truation and/or femininity are present.
3. Hormonal treatment with oral or parenteral pro-gesterone has been recommended by some, with good results.
4. In resistant cases, other drugs such as lithium, bromocrip tine, pyridoxine, antidepressants and anti- anxiety agents have been used with varying success.