Is My Stomach Pain in my Head?

This is a delicate issue and must be approached by medical professionals with care.  Of course, it is an established fact that psychic distress can be responsible for physical ailments.  Did you ever get a headache after having an argument?  Were you one of those students who experienced diarrhea before final exams?

Prior to my penning this post, I saw 3 new patients in my practice with abdominal distress all of whom volunteered that they felt that emotional stress and anxiety were the culprit, or at least was a major contributor to their gastro issues.  Obviously, when the patient has this level of insight and expresses it to the physician, it paves the way for a fruitful conversation.

But, this is not always the case.

When I see new patients with long histories of unexplained abdominal complaints, I do not initially raise the possibility of a psychic connection.  I think this is arrogant and has the potential to communicate the wrong message to the patient, even if stress-induced gastro distress is ultimately diagnosed.  My obligation as a gastroenterologist is to consider medical explanations of patients’ symptoms.  Patients with bipolar disease, anxiety and PTSD can develop ulcers, Crohn’s disease, cancer and appendicitis, etc.,  just like everyone else.  I do my best to keep my mind open so as not to miss a lurking medical condition.

And if a doctor raises the ‘mind-body connection’ too soon, it risks rupturing the doctor-patient relationship.  Once the relationship is better established, then deeper conversations become possible.

Is my headache real or just in my head?

Consider a patient who comes to see me for the first time with a history of anxiety and abdominal pain.  She has seen a digestive specialist who has been unable to explain her distress.  Should I suggest that her anxiety may be responsible and direct her toward treating this disorder?  Here are some of the pitfalls of that approach. 

• She may have a medical diagnosis that was missed by the prior specialist.
• Suggesting that anxiety is the cause, if done at the wrong time and in the wrong manner, risks communicating to the patient that the ‘pain is in her head’.  This may forfeit any opportunity to help this individual.
• Anxiety may be a contributor, but there may be other relevant medical conditions such as irritable bowel syndrome or constipation, which can be successfully addressed.
• Invoking anxiety in a general way may miss an important path forward.  For instance, the patient may have a fear of  a specific illness, beyond general anxiety.  Discovering this takes physician effort.  Knowing, for example, that a patient is scared that she may have an esophageal tumor is extremely useful to the doctor, who can address this directly.  A simple question of, ‘are you scared that you might have something serious’, can reveal a healing opportunity.

And while physicians need to tread this terrain carefully, patients have a responsibility here also.  Both sides need to be open to all reasonable diagnostic possibilities as they contemplate the complex tangled web of the mind-body relationship.