Psychogenic dysphagia

Psychogenic dysphagia is a syndrome of impaired swallowing within the framework of psychogenic disorders of tone and motility of the esophagus. The clinical picture is characterized by a feeling of a lump in the throat or behind the breastbone, as a result of which food gets stuck during eating and passes with difficulty or does not pass at all. In addition to difficulty swallowing, there is usually heartburn, pain in the sternum and various vegetative disorders. As a rule, two types of dysphagic disorders are distinguished depending on localization - oropharyngeal and esophageal.

Diophagic disorders require careful clinical and paraclinical analysis to exclude organic diseases of the nervous system, digestive tract and other diseases.

Dysphagia is an important phenomenon of various manifestations of motor disorders of the esophagus, in which the psychophysiological component plays a major role in the pathogenesis of suffering.

One of the primary disorders of esophageal motility is achalasia, or cardiospasm, - the loss of the ability for normal reflex relaxation of the cardia without any organic changes in the esophagus, stomach and mediastinal organs, despite a very long (sometimes over 20-30 years) duration of the disease. Special studies have shown a change in peristalsis and an increase in pressure (determined by a manometer) of the lower esophageal sphincter at rest. A characteristic feature of cardiospasm is the presence, in addition to dysphagia, of painful sensations behind the sternum, radiating to the left shoulder, which are relieved by atropine, amyl nitrite, nitroglycerin or parenteral administration of seduxen (relanium). In some patients, the pain decreases after regurgitation (burping) or the passage of a stopped lump of food into the stomach.

Diffuse spasm of the esophagus (corkscrew esophagus) is most often found in older people and manifests itself, in addition to dysphagia, with chest pain. Special studies using manometric measurements have revealed high-amplitude non-peristaltic contractions of the esophagus. When swallowing, a number of concentric esophageal constrictions located one under the other are revealed, in some cases forming a kind of spiral (hence the comparison with a corkscrew).

Dysphagic manifestations may be an expression of not only an increase, but also a decrease in the tonic tension of the esophagus. Thus, with atony of the esophagus, total or partial, difficulty in swallowing is associated mainly with the passage of solid food, while liquid food passes freely. In this case, endoscopic examinations (esophagoscopy, gastroscopy) do not encounter any obstacles. Patients experience a sensation of a foreign body along the esophagus; as a rule, there are also pronounced asthenic and depressive disorders. X-ray examination reveals low tone in other parts of the gastrointestinal tract, and a decrease in peristalsis is noted. A special case of impaired esophageal tone is cardia insufficiency - a decrease or loss of muscle tone in the cardiac part of the esophagus with regurgitation.

The above-mentioned motor and tonic disorders (cardiospasm, diffuse spasm of the esophagus, esophageal atony, cardia insufficiency), which largely determine the formation of the phenomenon of dysphagia, may be combined with broader motor-tonic disorders of the stomach and intestines. It is important to emphasize that the clinical picture may include psychovegetative disorders of varying degrees. Some patients are focused on the main phenomenon - swallowing disorder - and may not notice concomitant emotional and vegetative disorders. In other cases, only a highly professional psychoneurological analysis can reveal the connection between the occurrence and course of existing disorders and psychogenic situations, which is of fundamental importance for the positive diagnosis of pathogenic dysphagia.

Since swallowing disorder is a rather ominous sign of serious organic diseases, differential diagnostics should take into account all possible diseases in these cases. In case of oropharyngeal dysphagia, it is necessary to exclude systemic diseases (poliomyositis, dermatomyositis, non-specific granulomatous myositis), diseases of the neuromuscular system (muscular dystrophy, multiple sclerosis, parkinsonism, myasthenia, syringobulbia, motor neuron diseases, vertebrobasilar insufficiency), thyrotoxicosis, sarcoidosis, trichinosis. In case of esophageal dysphagia, the following should be excluded first of all: scleroderma, Chagas disease, foreign body of the esophagus, diverticula, peptic stricture, cervical osteoarthritis, esophageal tumors, esophagitis, aneurysm (aorta, subclavian artery, heart), retrosternal goiter, mediastinal tumors, exudative pericarditis.

The pathogenesis of psychogenic dysphagia is complex. It is necessary to highlight two interrelated aspects - subjective and objective changes. The mechanisms of formation of the subjective sensation of dysphagia are reflected in the above section "Lump in the throat". In dysphagia, in addition to the above mechanisms, the main pathogenetic link is of great importance - a violation of the tone and motility of the esophagus, which reflects the dysfunction of the regulatory mechanisms of the tone of the smooth muscles of the digestive tract. The combination of emotional (hypochondriacal, phobic, anxiety-depressive) and vegetative disorders in the patient as a result of psychogenic effects is the psychophysiological basis for the occurrence of psychogenic dysphagia. Fixation of the patient's attention on the act of swallowing with the formation of subsequent stability of the hypochondriacal attitude can be associated with a number of factors. For example, an exacerbation of anxiety-panic manifestations (panic attacks) in these patients causes a natural feeling of difficult (for these conditions) breathing - dyspnea. Random choking at this moment against the background of dyspnea and fear of death, which the patient usually experiences, the presence of elements of laryngospasm, especially in the presence of signs of increased neuromuscular excitability, can cause motor discoordination in the smooth muscle system of the pharynx and esophagus with the emergence of subjective and objective phenomena of the above nature. A decrease in the threshold of vegetative perception, which naturally occurs in these situations, causes hyperesthesia of the mucous membranes of the nasopharynx and esophagus, further aggravating the feeling of discomfort. In this case, a stable pathological system with feedback arises - a vicious circle, which is a factor in long-term persistence. Conversion mechanisms can be of great importance in a number of cases.

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