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Gastrointestinal Disorders of Psychogenic Origin: Management in Forward Areas
Lieutenant Colonel James A. Halstead (Ref 32)
Much has been written on the meaning of the term "psychosomatic," which in general connotes that every neurosis has a somatic manifestation and every disease a psychic component. In this section "psychosomatic disability" means an illness in which physical symptoms are predominant clinically and the patient complains primarily of physical rather than mental discomfort, but the cause of the illness is emotional conflict, not organic disease. Gastrointestinal disorders constituted the largest single group of psychosomatic disabilities among American soldiers in World War II. It is impossible to determine the exact proportion of gastrointestinal psychosomatic disorders because many ill-defined conditions, particularly orthopedic ones, have a psychogenic component that has not been analyzed statistically. In World War I cardiorespiratory manifestations of neurosis were more common than gastrointestinal symptoms, and much more common than they were in World War II. The reasons for this disparity are not entirely clear, though it is probable that the factor of suggestibility in the neurotic, which may make a particular syndrome assume the proportions of an epidemic, is an important one. Fashions in neurotic symptomatology change with the times, and the stomach was a favored center during World War II.
It is important that psychosomatic disorders be diagnosed correctly as early as possible. Labeling such patients with an organic diagnosis, such as gastritis, hepatitis, or peptic ulcer, in the case of gastrointestinal disorders, and treating them as having such a disease, tend to fix and magnify the symptoms. Loss of effective manpower ensues when these patients are evacuated to base section hospitals for an elaborate investigation to rule out organic disease. Their symptoms increase as long as there is a secondary gain from diagnostic hospitalization. Psychosomatic illness is a neurotic illness and should be treated as such. Since these patients are usually thought to have an organic disease, the general medical officer rather than the
(ref 32) Formerly of the medical service, Sixth General Hospital.
psychiatrist sees them first. He should, therefore, understand the psychodynamics involved in such illnesses. He should possess the experience and clinical judgment to differentiate the organic illness from the psychogenic and should be able to make a reasonably accurate diagnosis quickly with a minimum of laboratory facilities. It is important that this differentiation be made in the army area in order to salvage a significant percent of these men for combat.
In psychosomatic illness physiologic changes are set up in an organ by autonomic nerve impulses, generated as a result of emotional conflict or tension. Thus a patient may have cardiac palpitation or tachycardia, urinary frequency, diarrhea, vomiting, or gastric distress, as well as numerous other symptoms caused by disturbed function of an organ with autonomic innervation. Wolf and Wolff (ref 33) have demonstrated psychogenic changes in the gastric mucosa of a man with a large gastric fistula whom they studied with great care over a long period. In various states of emotional tension, such as fear and hostility, they noted reddening and engorgement of the mucous membrane, which often reproduced the picture of gastritis as seen by gastroscopy. When emotional tension was relieved the mucosa resumed its normal appearance. A psychogenic gastric disorderpsychogenic dyspepsia as it is called in this paperdoes not properly fall into the category of true conversion hysteria. Initially a psychogenic gastric disorder is one that accompanies anxiety, rather than acts as a substitute for it. The stomach symptoms themselves seem best explained primarily by the processes noted by Wolf and Wolff. (ref 33) They are the visceral manifestations of conflict, as anxiety is the mental expression. Once the gastric symptoms have become a prominent part of the clinical picture, however, they may acquire some of the characteristics of a true conversion. The symptoms themselves may come to offer the patient a partial solution of his conflict and thus give some protection against anxiety. Hence the degree of overt anxiety noted by the physician, or of which the patient is conscious, varies greatly.
Ref 33 Wolf, S. G. and Wolff, H. G.: Human Gastric Function; An Experimental Study of a Man and His Stomach. New York: Oxford Medical Publications, 1943.
In most instances the soldier with psychogenic gastrointestinal illness can continue to perform combat duty, provided early diagnosis is accomplished and the true nature of the symptoms is explained to him. It should be kept constantly in mind that psychogenic symptomatology may represent a "flight into illness" and that the longer the patient is treated as possibly having a physical illness, the less willing he will be to tolerate his symptoms and remain on duty in spite of them. Particularly is this true of the patient evacuated to a base section hospital.
Why is this so? First, the soldier has been removed from the rigors of front-line existence and allowed to relax into the comforts of hospital life, where he faces no responsibility. Quite naturally he does not wish to return to his former existence. Second, he has been removed from his unit, to which he has ties of loyalty. To the American soldier, this unit identification is the strongest motivation for fighting and enduring hardship and danger. The longer he is away from his unit the weaker this motivation becomes. Third, the sense of guilt because of failure, usually possessed by the soldier with a pure anxiety state, does not exist to the same degree in the soldier whose anxiety is overshadowed by physical symptoms, especially when his disorder is treated as a physical illness. He feels justified in leaving his job because he believes himself to be physically ill. The symptoms provide an automatic solution to the two basic conflicts of self-preservation and self-respect. With monotonous uniformity these soldiers say: "I want to go back and do my part, but my stomach won't let me." If the medical officer focuses his attention on the stomach and treats the symptoms, without recognizing or dealing with the neurosis that causes the symptoms, the patient cannot be blamed for believing that his stomach will not let him go back. Psychogenic stomach symptoms in soldiers do not disappear as a result of medicinal treatment or rest. The "flight into illness" should be arrested as quickly as possible. Not only is the halting of this escape mechanism of therapeutic value for the neurosis, but also is it of practical military value in saving manpower. A correct diagnosis and evaluation of duty potential, with prompt discharge from medical channels, either to full duty or limited service, can be accomplished in most cases after a few days of observation in the army area.
This early evaluation is of distinct advantage in checking the intensification of symptoms that occur from too much hospitalization. It can be achieved if the army area has administrative facilities for speedy reclassification of soldiers unfit for combat. A man with a neurotic reaction will become sicker if he remains too long a patient in a hospital, instead of returning to duty. If the neurosis precludes combat, the soldier may still contribute much in a limited service assignment. Mira (ref 34) pointed out the psychotherapeutic value of this principle in the Spanish Civil War. The preservation of effective manpower, not exhaustive medical investigation, is the primary mission of the Medical Corps. The essential problem in psychosomatic disorders is to differentiate organic from psychogenic illness.
Ref 34. Mira, Emilio: "Psychiatry in the Spanish Republican Army," in Psychiatry in War. New York: W. W. Norton & Company, 1943.
DIFFERENTIAL DIAGNOSIS OF PSYCHOGENIC AND ORGANIC GASTROINTESTINAL DISORDERS
The diagnosis of psychogenic disease is arrived at by the absence of evidence of organic disease, and the presence of evidence of psychoneurosis. These criteria have equal weight. A patient with a neurosis may likewise have organic disease, but in both instances the combination is unlikely statistically. In the differential diagnosis of gastrointestinal disorders orders equal emphasis should be given to the possibility of an organic and a psychogenic explanation, and each should be ruled out or in by appropriate examination. In military medicine, however, it is neither feasible nor advisable to examine patients as thoroughly as one might in civil practice. To do so would entail the evacuation of every soldier with an obscure gastrointestinal complaint to a base hospital, with disastrous results, both military and medical. The responsibility for ruling out organic disease should be taken by a medical officer at the most forward echelon possible. Clinical judgement is more valuable than laboratory or x-ray facilities. With these considerations in mind it is possible to diagnose and effect disposition in the army area of 90 percent of the soldiers hospitalized for gastrointestinal complaints. Such disposition was effected in the case of 776 patients under my supervision in a 6-month period at an army installation designated as a gastrointestinal center. Certain guides may be useful in differentiating organic disease from psychogenic disorders, namely, the history, the response to treatment, and statistical information.
The history is the most important part of the examination of a patient with a chronic gastrointestinal complaint. It is of far greater value than laboratory examination or even x-ray studies, though the latter are necessary in a certain number of cases. Too often the history is limited to the presenting episode, when a complete past history would make the diagnosis clear. The history should be inclusive and accurate with respect to symptoms, and it should relate the past history of poor digestion to the circumstances surrounding its onset and exacerbations. It should always include a personal history giving a brief survey of the patients life, family relationships, education, marital relationships, and work record, as a means of evaluating the patients personality. Of great significance is the military historylength of service, length of time overseas, and amount of combat duty. The relationship of symptoms to each of these episodes may provide
important clues. If the patient has adjusted well in the Army he is somewhat less likely to have a neurotic illness. Gastrointestinal symptoms that began before Army service and have continued without real remission are more likely to be psychogenic than organic. On the other hand, symptoms of brief duration should make one more alert for organic disease. Symptoms of vague and varied nature, not characteristic of any organic disease, are usually psychogenic. A thorough physical examination is important not only because it may occasionally reveal signs that point to a diagnosis, but also because if the disorder is diagnosed as psychogenic the examination is of therapeutic value in convincing the patient that the physician is right. Thus the authority of the physician is enhanced if he has made a thorough examination. With some experience the medical officer without formal psychiatric training can learn to diagnose psychogenic disease accurately. He will require psychiatric consultation in diagnosing doubtful cases and also in determining whether a neurosis is severe enough to warrant reclassification to limited service.
Response to treatment. The symptoms of patients with a psychogenic gastrointestinal disorder ordinarily do not respond to medicinal or dietary treatment or to rest, while those of patients with organic disease usually do. The symptoms of peptic ulcer nearly always abate in a few days if the patient is given frequent feedings and alkalis. In hepatitis without jaundice the gastrointestinal distress and malaise often diminish after rest in bed. The symptoms of a psychogenic gastric disorder simulating these two diseases are usually not internally influenced by such measures. The diarrhea of bacillary dysentery usually subsides promptly with sulfonamide therapy, whereas diarrhea of psychologic etiology is not affected. A psychogenic backache usually responds slowly or not at all to such measures as rest and heat, whereas an acute backstrain does respond. The information provided by response to treatment is thus a valuable guide in differentiating psychogenic and organic disease, of whatever type.
Statistical information. Table VIII shows the results of a thorough investigation of 140 patients with chronic complaints referable to the upper gastrointestinal tract at a general hospital in Italy between 1 July and 18 November 1944. These patients, who arrived at the hospital within a few days after leaving their combat unit on the Italian front, were somewhat selected in that they had been observed for a short period in evacuation hospitals. As table VIII shows, in only 20 percent was organic disease demonstrated. At another general hospital in Italy in the same period 24 percent of patients with chronic gastrointestinal complaints were found to have organic disease. In unselected patients seen at forward echelons the
proportion of patients with organic disease was much lower. For example, of 220 patients with chronic epigastric distress only 7 (3.3 percent) had peptic ulcer. Of the remainder, about 70 percent had psychogenic dyspepsia and 25 percent had ill-defined conditions; that is, no definite disease could be found.
Diagnoses of 140 patients with chronic upper gastrointestinal disorders
In civil practice at least 50 percent of chronic gastrointestinal disorders are attributable to disturbed function rather than organic pathology. Organic disease is more common in the general population than in the Army age group, in which malignancy and gall bladder disease are rare. The gastrointestinal tract notoriously reflects emotional upset, which is common in the Army. Thus on the basis of probability alone a chronic gastrointestinal disorder in a soldier is more likely to be psychogenic than organic.
Because of the low incidence of organic disease and the high incidence of neurosis among soldiers who complain of chronic gastric discomfort, it is safe to adopt the following criteria in the diagnostic evaluation of such patients in the army area: if the symptomatology does not fit in with any organic disease, the physical examination is negative, and the clinical findings concerning temperature, urine, stool, and blood are all normal, symptomatology should be disregarded and a psychiatric appraisal should be made. The answer will usually be found in this sphere. An exhaustive search for an organic explanation of symptoms by prolonged medical and laboratory investigation will be harmful to the 70 percent of patients who have psychogenic dyspepsia, and many men will be lost to the services. In dealing with the chronic stomach complaints of soldiers, the occasional diagnostic error that may be made is not likely to be serious.
CLINICAL TYPES OF GASTROINTESTINAL DISEASE
Psychoneurosis, peptic ulcer, hepatitis, diarrhea, and parasitic disease, the commonest causes of gastrointestinal complaints among soldiers, accounted for at least 95 percent of cases. The role of chronic gastritis was uncertain. Gall bladder disease was seldom encountered. A brief discussion of the clinical features of each of these manifestations follows.
The varied clinical picture of psychogenic dyspepsia seen in soldiers in a forward area depends on the amount of combat proceeding at the time. During active combat free anxiety is a prominent feature in the majority of patients, who are nervous and tense and experience battle dreams. This state is rarely as severe as that seen in soldiers evacuated from battle to the army psychiatric center with an acute anxiety state. Such soldiers seldom have gastrointestinal symptoms of severe degree. During a quiescent period, when troops are in a defensive position, such as occurred in the early winter of 1945 on the Italian front, the patients seen at the Fifth Army Gastrointestinal Center rarely had overt anxiety and showed little difference from the clinical findings observed in service troops in the base section.
The majority of patients had experienced symptoms for several years. Thus, 72 percent of a group of 100 consecutive patients studied by me had had symptoms before entering the Army. During a period of more active combat, however, there were greater numbers with symptoms of briefer duration. Characteristically, there was little or no remission during which the patient felt entirely well, regardless of what he ate. Often the symptoms had never been severe until the soldier entered the Army, and with each entry into a less stable or more dangerous environment there had been an exacerbation. Frequently soldiers had been hospitalized at these times. The soldier admitted little improvement during such hospitalization. He often said: "They didn't tell me what was wrong," or "They said it was a nervous stomach, but I am sure it was those C rations." (ref 35) Not much significance could be attached to a soldier's statement that he had had "ulcers of the stomach" at one time in civil life, since in many cases it was a diagnosis based on a physician's statement, or the patient's interpretation of such a statement, without roentgenographic evidence.
Ref 35. Field ration C consists of 6 cans per ration of previously cooked or prepared food, packed in hermetically sealed cans, which may be eaten either hot or cold as follows: 3 cans containing a meat and vegetable component; 3 cans containing crackers, sugar, and soluble coffee (from AR 30-2210, 15 March 1940.)
The symptoms of psychogenic dyspepsia are varied. Among these soldiers the patient usually complained of epigastric distress, a burning
feeling, or heartburn immediately afterward, rarely after an interval. Usually the soldier had a good appetite, but felt full after eating a few mouthfuls. Baking soda occasionally relieved the distress, but food rarely did. Vomiting was common, but on close questioning it was found to consist of regurgitation of a few mouthfuls. Occasionally the patient vomited regularly after breakfast. Altered bowel habits were uncommon, although in patients with much free anxiety there was sometimes slight diarrhea, lasting a few days at a time. Nearly always such patients looked well and were not malnourished or dehydrated. Not infrequently they complained of gastric distress associated with exertion. Diaphragmatic hernia was considered in such instances, but was not found. Frequently these patients had other symptoms, such as dizziness or lightheadedness, insomnia, inability to relax, pains in the chest, palpitations, and headache. As in most psychoneuroses, they complained of feeling tired, particularly in the morning.
In about three-fourths of the patients a family history of indigestion was elicited. In these patients the mother or father had chronic dyspepsia. These patients frequently had had lifelong food idiosyncrasies and were likely to be fussy about their food. Although they were convinced that diet was of paramount importance in the etiology of their symptoms and that their difficulties were caused by C rations alone, they rarely felt much better when given a bland diet in the hospital. What they wanted, consciously or unconsciously, was relief from unpleasant duty. Although if a decision had been made to send them home or reclassify them, they usually complained much less, relief did not bring a cure. The mechanism is much deeper and more complicated than mere reaction to unpleasant situations.
The personality pattern of patients with psychogenic dyspepsia is strikingly different from that of peptic ulcer patients. They are outwardly submissive and unaggressive, but one senses underneath a pronounced degree of hostility and resentment. Usually it is difficult to achieve rapport with these patients. They show abnormal concern over the stomach, magnify their symptoms, and obviously desire to impress the medical officer with the gravity of their distress. They rarely "feel well," are usually tired, and have other similar complaints. A characteristic feature is their resistance to accepting the explanation that their symptoms are psychogenic. Often they say, "Yes, I know I am nervous, but my stomach makes me that way." In view of the psychodynamics of the illness it is easy to see why patients wish to be considered organically ill, and why it is strongly to their interest to believe they are.
When there was little apparent anxiety these patients were often considered to have all organic disease such as hepatitis, chronic gastritis,
or peptic ulcer. Many such patients were evacuated to the base section for further study. Careful evaluation of symptoms, psychiatric examination, and, when necessary, a therapeutic trial on a soft diet with alkalis for a few days, was sufficient to establish the diagnosis with reasonable assurance of its being correct in all but a few patients.
Ordinarily it is unwise to attempt routine gastrointestinal fluoroscopy in the army area. Accurate fluoroscopic examination requires not only the services of an expert roentgenologist, but also more elaborate equipment than is available in the army area. Without such personnel and facilities organic lesions may be missed and transient fluoroscopic abnormalities may be considered pathologic lesions. It is usually best, therefore, to decide on a clinical basis whether to return the patient to duty or to evacuate him for further study.
In about 10 percent of the patients reasonably accurate differential diagnosis of psychogenic and organic disease cannot be made without gastrointestinal fluoroscopy. Of 113 consecutive patients with dyspepsia who were x-rayed at the Fifth Army Gastrointestinal Center as part of an intensive clinical and gastroscopic study, only 4 had ulcer, though on the basis of their history all were believed to have ulcer. Six additional patients were believed to have ulcer from a history in which the roentgenograms were negative. In no case, in a group of 190 patients with dyspepsia who were x-rayed, was ulcer demonstrated when the clinical diagnosis was psychoneurosis. Thus it would appear that the possibility of ulcer is slight in a patient in whom the clinical diagnosis is psychogenic dyspepsia. Although from a purely diagnostic point of view roentgenographic study is not often necessary, it has great therapeutic value in convincing the patient that he has no organic disease, and it is, therefore, recommended when adequate roentgenographic facilities are available. It is also helpful to the battalion surgeon to have a negative roentgenographic report if the patient returns to sick call with the same complaint. For those patients in whom insight is not obtainable by explanation alonethat is, between 30 and 70 percent of patients, depending on the circumstances of combat and the degree of free anxietyroentgenographic examination is recommended. (When free anxiety is present it is more often possible to give the patient insight.) The value of therapeutic roentgenographic examination is not great enough to warrant evacuation when adequate radiologic facilities are not available in the army area.
The clinical features of peptic ulcer should be well understood in order to differentiate it from psychogenic dyspepsia. The typical
ulcer symptomatology is present in between 70 and 80 percent of soldiers with ulcers. The symptoms may not always be typical of ulcernamely, dull, gnawing epigastric pain occurring 2 hours after a meal and relieved by foodbut almost invariably there are certain distinctive features. Perhaps the most important is that if symptoms have existed for several years there are remissions lasting a few months, during which the patient can eat what he likes without discomfort. Peptic ulcer is a chronic, recurrent disease. The patient may be wakened at night by pain, an uncommon symptom in psychogenic dyspepsia. Drinking water, eating food, or induced vomiting will usually relieve the pain of peptic ulcer. Vomiting was not a frequent symptom of ulcer among soldiers. The personality of the ulcer patient is usually very different from that of the patient with a psychogenic gastric disorder. He is aggressive, tense, and independent, a good soldier, often a leader, restless and ambitious. Rapport with the ulcer patient is easily obtained. He does not visit sick call at the first sign of distress, as the patient with psychogenic dyspepsia is likely to do. He tells a straight story, and it is easy to obtain a clear-cut history from him. He rarely has other symptoms and does not magnify his distress to the medical officer. Frequently, in spite of gastric distress, he sincerely wishes to return to duty. Table IX outlines factors in the differential diagnosis of peptic ulcer and psychogenic dyspepsia.
TABLE IXDifferential diagnosis of peptic ulcer and psychogenic dyspepsia
Chronic gastritis can be diagnosed with accuracy only by gastroscopy, although in severe cases enlarged gastric rugae as seen roentgenographically are suggestive. The incidence, clinical features, and interpretation of gastroscopic findings are debatable. Although Annis (ref 36) and Gold (ref 37) each report that in Army hospitals in the United States about 35 percent of patients with nonulcerous dyspepsia had chronic gastritis, the interpretation of such changes is uncertain. Montgomery, Schindler, et al. found that in a naval hospital 11 of 22 patients with chronic nonulcerous dyspepsia had a normal gastric mucosa and 11 had some form of gastritis, of which 5 were classified as mild or insignificant. (Ref 38) Examinations of the 22 patients by a psychiatrist showed that 11 had a marked neurosis, 6 a mild neurosis, and 5 were normal, but 2 of the normal group were restless and high-strung.
In a careful clinical, radiologic, psychiatric, and gastroscopic study of 109 consecutive patients with chronic nonulcerous dyspepsia, conducted at the Fifth Army Gastrointestinal Center by two internists, one of whom was experienced in gastroscopy, a psychiatrist, a clinical psychologist, and a radiologist, the following findings were obtained: 59 percent of the patients had a normal gastric mucosa; 26 percent showed slight abnormalities, consisting of redness and increased high lights; and 15 percent showed more marked changes, with edema and adherent mucus. These changes are considered by Schindler (ref 38) to be the signs of chronic superficial gastritis. In 9 patients spasm of the antrum or midbody was seen without changes in the mucosa. No cases of hypertrophic or atrophic gastritis were found. Psychiatrically, no differences were noted between the group showing gastroscopic changes and the group with a normal gastric mucosa. It was believed that the benign changes noted gastroscopically could best be explained on a circulatory basis related to chronic anxiety. The symptomatology of 67 percent of the patients dated back several years, often to childhood. Since 75 percent of the group had a pronounced neurosis it seemed logical to suppose that the changes were the result of neurosis, not of an inflammatory disease independent of neurosis as some investigators believe. This hypothesis of neurotic change is strengthened by the observations of Wolf and Wolff, (ref 33) who
(ref 36) Annis, J. W.: Gastritis in the Military Service,
Gastroenterology : 2, 85-92, 1944.
demonstrated transitory changes indistinguishable from gastritis in the gastric mucosa of their subjects with a gastric fistula when he was in a state of emotional tension. If a patient with positive evidence of psychoneurosis has chronic dyspepsia it is important not to make a diagnosis of gastritis in the absence of undoubted gastroscopic evidence of hypertrophic or atrophic gastritis. Such a diagnosis will more readily fix the symptoms and make it more difficult to salvage the soldier. We know that a neurosis may cause epigastric distress, but as yet we have no exact knowledge or complete agreement among gastroscopists about the significance of gastroscopic changes.
Hepatitis is common among troops. It exists both with and without jaundice. The incidence of hepatitis without jaundice is a matter of dispute, though undoubtedly it is an entity. It may be acute, recurrent, or chronic. Without jaundice, hepatitis may be difficult to diagnose, and psychoneurosis should be considered in the differential diagnosis. Liver function tests are usually, though not always, helpful in establishing the diagnosis. The history is the most important method of examination. Symptoms of brief duration in a patient without evidence of psychoneurosis are in favor of acute hepatitis. The usual symptoms are anorexia, appearing suddenly, malaise, and upper abdominal distress, frequently with dull pain in the right upper quadrant, especially on bending over or jarring. There is usually fever of variable degree, sometimes accompanied by chills. The liver is usually enlarged and tender. Evaluation of tenderness of the right upper abdominal quadrant and of the size of the liver is difficult in borderline cases, particularly as many patients with psychogenic dyspepsia have tenderness of the right upper abdominal quadrant. Diarrhea was a precursor of hepatitis in the majority of patients seen in the Italian theater. Diarrhea is not usually a feature of psychogenic dyspepsia, although psychogenic diarrhea is a real entity.
Laboratory tests of value are the leukocyte count, the bromsulfalein test, the icterus index test, and tests for bile in the urine. The leukocyte count is between 3,000 and 5,000, with an increased number of immature lymphocytes. While bromsulfalein clearance is the most reliable test for measuring liver damage, it is usually not available in forward areas.
When hepatitis is suspected the patient must be carefully observed, often for 10 days to 2 weeks, before the diagnosis is reasonably certain. It is, however, seldom difficult to decide whether the patient's symptoms are the result of neurosis or organic disease.
The laboratory tests mentioned should be repeated at intervals. Daily examinations should be made of the liver, and the urine should be tested daily for bile. In acute hepatitis without jaundice, bile may appear transitorily. The patient's personality should be evaluated for neurotic factors. If jaundice is to develop it will do so within 14 days in most patients. The diagnosis of chronic hepatitis may be made on the basis of a previous history of jaundice, an enlarged and tender liver, and fatigue, anorexia, and indigestion after exercise. Here again psychoneurosis needs to be considered. All factors, including liver function tests, should be evaluated before a decision is made.
Diarrhea is the most common gastrointestinal symptom among troops, and there was much chronic or recurrent diarrhea among soldiers in the Italian theater. In soldiers the possibility of psychogenic diarrhea must be considered. Of 303 patients with diarrhea seen at the Fifth Army Gastrointestinal Center, 39 were diagnosed as of psychogenic origin. These 39 patients all had a pronounced psychoneurosis and a long history of intermittent mild diarrhea. Repeated cultures, proctoscopic examination, and examinations for amebas were all negative. In a group of 110 patients with chronic diarrhea of undetermined cause, evidence of significant neurosis was lacking. Anxiety was present in many patients, probably because the diarrhea occurred in the drive on the Gothic Line. Bacillary dysentry was also prevalent at the time. It was concluded that while psychogenic factors often played a part in prolonging or intensifying an infectious diarrhea, they were not the primary etiologic factors in most cases of persistent diarrhea.
In differentiating infectious from psychogenic diarrhea the criteria outlined abovenamely, the history and response to treatmentare applicable. Infectious diarrhea, which is nearly always bacillary dysentery, usually begins suddenly and as a rule, is accompanied by fever. Although blood may be present in the stools, since the patient often cannot observe his stools when using latrines in the field, a negative statement about bloody stools is not significant. Nausea, vomiting, and abdominal cramps are characteristic. In psychogenic diarrhea the same symptoms may be present, except for fever and the appearance of blood. The most important feature in psychogenic diarrhea is a previous history of repeated attacks of diarrhea during dangerous or traumatic episodes. A further requirement for this diagnosis is a neurotic or unstable personality. Normal persons may have diarrhea during great nervous stress, but usually it does not persist more than a day or two. Bacillary dysentery or amebiasis may be the cause of chronic diarrhea in a psychoneurotic patient. Only by proctoscopic study, repeated microscopic examinations, and cultures can organic disease be ruled out.
Ankylostomiasis, ascariasis, amebiasis without dysentery and other intestinal parasitic diseases may cause indefinite gastrointestinal symptoms and must be considered in diagnosis. The stool should be examined for parasites in every case of chronic or indefinite gastrointestinal symptoms.
Gall Bladder Disease
Gall bladder disease is uncommon in the age group that includes most soldiers and need not be entertained seriously as a diagnosis unless the clinical findings are fairly characteristic, in which case the patient should be evacuated to a general hospital for further examination.
TREATMENT AND DISPOSITION OF PATIENTS WITH PSYCHOGENIC
Treatment and disposition are discussed together, since early disposition in itself constitutes the single most important factor in therapy. Ideally, patients with psychogenic disorders should not be hospitalized at all. The unit medical officer should make his diagnosis and disposition from ordinary examination. Occasionally ulcer or other organic disease may be missed by this procedure, but experience has shown that catastrophes rarely result from such an error. A certain number of patients, however, must be evacuated from forward units when there is insufficient time for examination in combat and when there is justifiable doubt as to the diagnosis. Moreover, a brief but thorough clinical examination in a forward hospital has therapeutic value for the patient without free anxiety or insight.
In civil practice treatment of psychogenic gastrointestinal disorders by rest, special diets, antispasmodic drugs, and sedatives usually brings temporary symptomatic relief. In the Army, particularly in a combat zone, the secondary gain from illness is so great that such measures rarely provide relief. It is so much to the interest of the psychosomatic patient to remain ill that symptomatic relief cannot be expected from medication. Psychotherapy, by manipulation of the environment, persuasion, suggestion, or explanation, is the only means whereby a cure may be effected. In military medicine these measures are effective only in a limited way. In one sense it is therapy to limit the neurotic's possibilities for escape by limiting his possibilities for perpetuation of symptoms. In many instances, through firm and prompt management, with discharge from the hospital
as soon as the diagnosis is made, the patient improves, and performs useful combat service when returned to duty. When his neurosis is not catered to, he is forced to face reality. Unit morale plays a major role in helping him to live with his symptoms. It has been postulated that prolonged functional changes from emotional conflict may lead to such structural changes as chronic gastritis or peptic ulcer. As yet this possibility has not been proved, and it is not on sufficiently firm ground to warrant taking it into consideration in deciding on the disposition of a patient.
When a psychogenic gastrointestinal disorder has been diagnosed, it must be decided whether the patient is to be returned to full duty, reclassified for limited service, or sent to the zone of the interior. The decision is almost entirely a psychiatric problem. Except in patients with intractable vomiting, dehydration, or severe diarrhea, the physical symptoms of themselves are of minor importance as compared to the severity of the neurosis. The number of previous hospitalizations must be taken into account. If the soldier has been recently hospitalized twice in addition to his current hospitalization, it is usually a waste of time to return him to full duty. It is seldom necessary, however, to send a soldier to the zone of the interior, although in the early part of the North African campaign it was often necessary to do so because of prolonged hospitalization. Of 141 patients discharged with psychogenic gastric disorders from a general hospital in Morocco between March and October 1943, 16 percent were returned to full duty, 22 percent were reclassified for limited service, and 62 percent were returned to the zone of the interior. Of the 38 percent discharged to duty or limited service, nearly half were rehospitalized and then sent to the zone of the interior.
This unfavorable result was probably caused by several factors: (1) many of the patients were service troops from base section areas whose neuroses were presumably severe, for they were hospitalized as a result of relatively little environmental provocation; (2) at that phase of the North African campaign the attitude and policy of medical officers were more lenient than they were later; (3) too much attention was paid to symptoms, and it was not then fully appreciated that overhospitalization and too much medical investigation had a bad effect on soldiers with psychosomatic disorders; and (4) the patients from combat units had been in hospitals for several weeks in the chain of evacuation, with resultant fixation of symptoms. After this same hospital had moved to Rome, 112 patients, nearly all infantrymen, with psychogenic gastric disorders were discharged between July and November 1944. Of these, 55 percent were returned to full duty and 45 percent were discharged to limited service. This marked improvement resulted from the fact that patients reached the hospital only a few days after leaving their units, instead of several weeks later, as in Morocco.
A still greater number were returned to duty when patients were examined in the army area. In a 6 months period 79 percent of 286 patients were able to return to full duty. These patients were received the day they left their units in army installation serving is a gastrointestinal center. The average duration of hospitalization, from the day they were evacuated to the date of discharge to duty, was 7.8 days. Those reclassified for limited service spent two or three more days in a convalescent hospital where board proceedings for reclassification were conducted. It may be objected that the lower percent returned to full duty from a general hospital in Rome was the result of more efficient disposition at forward areas, with only the more severe cases being evacuated. I was in charge of patients at both levels and could detect no difference in the severity of the neurosis or in the clinical findings, except that in Rome the symptoms were more fixed and the patients were much less willing to return to duty. Furthermore, since it is known that many of these patients were evacuated because bed space was required for battle casualties, the lower percent of patients returned to duty is attributed mainly to their prolonged hospitalization.
The effectiveness of soldiers with psychogenic gastrointestinal disorders has been studied, with the results shown in tables X and XI. An investigation of 61 patients returned to full duty from a convalescent hospital in the period of heavy combat was first made by means of a questionnaire (table X). The study indicated that these soldiers functioned as well as any patient with a mild neurosis. An additional follow-up study of 95 patients returned to full duty from the Fifth Army Gastrointestinal Center in a period of defensive action revealed a satisfactory degree of effectiveness; that is, 83 percent remained on duty from 1 to 4½ months after discharge (table XI).
Status of 61 soldiers with psychogenic gastrointestinal
disorders, 5 to 8 weeks after discharge to full duty from a
(ref 1) Based on reports from company commanders.
Status of 95 soldiers from 4 infantry divisions with psychogenic gastrointestinal disorders 1 to 5 months after discharge from Fifth Army Gastrointestinal Center
Interviews with the squad leaders of 50 of these men revealed that 34, or 68%, were considered average or even superior soldiers (Table XII)
Effectiveness of 50 men returned to duty (ref 1)
(ref 1) As determined by interviews with squad leaders. The majority of squad leaders interviewed stated that these soldiers did not complain unduly of stomach symptoms to other men in the squad or visit sick call frequently, a result indicating the therapeutic value of early limitation of the avenue of escape and the value of unit morale.
After the diagnosis of a psychogenic disorder has been made and it is decided that the soldier is to be returned to duty, he must be told firmly, though sympathetically, that he will have to live with his symptoms; that it is understood he does not feel entirely well and is not goldbricking. It is of great importance that the medical officer treat the soldier as a man with a mild illness that is not disabling. Such treatment may be of great therapeutic value and in may also give the patient a certain degree of security. The soldier should be told that few soldiers feel entirely well in combat and it is expected that he, like others, can carry on in spite of discomfort; that he has no serious organic disease and that his distress is caused by nervousness. Patients who deny anxiety, as many do, may be told that, although
they do not feel nervous, their nervousness, centered in the stomach, causes it to behave abnormally. The altered function involved should be explained in such a way that the patient can understand it.
Often the soldier will not accept the explanation given and becomes resentful. Nevertheless, the medical officer should not reverse the decision once it is made. Under no circumstances should he tell the soldier to "go back and try it," for the soldier will then immediately report to sick call, under the assumption that his own serious doubts as to his ability to carry on are shared by the physician. A clear-cut decision must be made by the medical officer and must be firmly communicated to the patient. Reclassification or reassignment should never be mentioned, for these are what the soldier with a psychosomatic disorder seeks. If the medical officer suggests these possibilities by careless talk the soldier will try to be reevacuated through conscious or unconscious intensification of his symptoms. For the same reasons a note suggesting reassignment within the division should never be sent with the soldier for his unit medical officer. Soldiers always read such notes and naturally deduce that they are not fit for combat. A unit medical officer has a right to expect that a patient returned to full duty is fit for it. If he is not fit, reclassification proceedings should be carried out at the hospital.
In a majority of soldiers chronic gastrointestinal complaints are psychogenic. Hospitalization has an adverse effect on patients with psychogenic disorders. When chronic gastrointestinal disorders are quickly diagnosed and evaluated within the army area, there is a marked saving of manpower.