Psychogenic dysphagia

Psychogenic dysphagia is a syndrome of impaired swallowing within the framework of psychogenic disorders of the tone and motility of the esophagus. The clinical picture is characterized by a sensation of a coma in the throat or behind the breastbone, as a result of which food gets stuck during the meal and hardly passes or does not pass at all. In addition to difficulty swallowing, there are usually heartburn, pain in the sternum and various vegetative disorders. As a rule, two types of dysphagic disorders are distinguished depending on the 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 large role in the pathogenesis of suffering.

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

Diffusive spasm of the esophagus (esophagus in the form of a corkscrew) is most common in the elderly and manifests, in addition to dysphagia, sternal pains. Special studies with the help of manometric measurements revealed high-amplitude non-hyperstatic contractions of the esophagus. When swallowed, a number of concentric constrictions of the esophagus located under each other are revealed, forming in some cases a kind of spiral (hence the comparison with the corkscrew).

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

These motor and tonic disorders (cardiospasm, diffuse spasm of the esophagus, atony of the esophagus, cardia deficiency), which in many respects determine the formation of the phenomenon of dysphagia, can be combined with more extensive motor-tonic abnormalities from the stomach and intestines. It is important to emphasize that in the clinical picture there may be presented psycho-vegetative disorders of one degree or another. Some patients focus on the main phenomenon - impaired swallowing - and may not note concomitant emotional and autonomic disorders. In other cases, only a highly professional psychoneurological analysis can reveal the connection between the occurrence and course of existing disorders with psychogenic situations, which is of fundamental importance for the positive diagnosis of pathogenic dysphagia.

Due to the fact that the swallowing disorder is a rather ominous sign of serious diseases of an organic nature, in differential diagnosis all possible diseases in these cases must be taken into account. With oropharyngeal dysphagia, systemic diseases (poliomyositis, dermatomyositis, nonspecific granulomatous myositis), neuromuscular diseases (muscular dystrophy, multiple sclerosis, parkinsonism, myasthenia gravis, syringobulbia, motor neuron diseases, vertebrobasilar insufficiency), thyrotoxicosis, sarcoidosis, trichinosis should be excluded. Esophageal dysphagia should first of all exclude scleroderma, Chagas disease, foreign esophagus, diverticula, peptic stricture, cervical osteoarthritis, esophageal tumors, esophagitis, aneurysm (aorta, subclavian artery, heart), retrosternal struma, mediastinal tumors, exudative pericarditis.

The pathogenesis of psychogenic dysphagia is complex. Two interrelated aspects should be distinguished: subjective and objective changes. The mechanisms of the formation of a subjective sensation of dysphagia are reflected in the section "Comes in the throat" described above. In dysphagia, in addition to these mechanisms, the main pathogenetic link, the violation of the tone and motor of the esophagus, is of great importance, which reflects the dysfunction of the regulatory mechanisms of the smooth muscle tone of the digestive tract. The combination of emotional (hypochondriacal, phobic, anxiety-depressive) and vegetative disorders in a patient as a result of psychogenic influences is the psychophysiological basis of the emergence of psychogenic dysphagia. Fixing the patient's attention to the act of swallowing with the formation of the subsequent stability of the hypochondriacal system can be associated with a number of factors. So, for example, the aggravation of anxiety-panic manifestations (panic attacks) in these patients causes a natural sensation of difficulty (for these conditions) breathing - dyspnea. Accidental choking at this moment against the background of dyspnoea and fear of death, which is usually experienced by the patient, the presence of elements of laryngospasm, especially in the presence of signs of increased neuromuscular excitability, can cause motor discoordinations in the smooth muscle system of the pharynx and esophagus with the emergence of subjective and objective phenomena of this nature . Reducing the threshold of vegetative perception, which naturally arises in these situations, causes hyperesthesia of the mucous membranes of the nasopharynx and esophagus, further exacerbating the feeling of discomfort. In this case, a stable pathological system with feedback arises - a vicious circle that is a factor of persistent persistence. In many cases, conversion mechanisms are of great importance.