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REVISTA ROMNDE PEDIATRIE VOLUMUL LXII, NR. 1, AN 2013 11

Adresa de coresponden:Dr. V.V. Lupu, Universitatea de Medicini Farmacie Gr. T. Popa, Str. Universitii nr.16, Cod 700115, Iaie-mail: [email protected]

ABORDAREA PSIHOSOMATIC A BOLILORDIGESTIVE LA COPIL

Ana-Maria Ciubara1, Gabriela Pduraru2, Ancua Ignat2, Amalia Constantin2,Smaranda Diaconescu2, V.V. Lupu2, M. Burlea2

1Disciplina Psihiatrie, UMF Gr. T. Popa, Spitalul Clinic de Psihiatrie Socola, Iai2Disciplina Pediatrie, UMF Gr. T. Popa, Clinica V Pediatrie-Gastroenterologie,

Spitalul Clinic de Urgene pentru Copii Sfnta Maria, Iai

REZUMAT

Bolile psihosomatice sunt acele afeciuni medicale a cror apariie i/sau evoluie este determinat, n modsemnificativ, de factori psihologici. Principalele tulburri digestive n care factorul psihosomatic este prevalentsunt: afeciunile gastroduodenale, esofagitele corozive, constipaia, encompresis, diareea emoional, sindromulcolonului iritabil, rectocolita ulceroasi boala Crohn. Conduita terapeutic se bazeaz pe strnsa colaboraredintre psiholog i pediatrul gastroenterolog. Psihoterapia de susinere este necesar pentru completareamedicaiei. Copilul trebuie s primeasc suport emoional i ajutat s i neleag sentimentele fa de situaiade boal traversat. Medicul trebuie s realizeze o relaie de ncredere, s dezvolte o atitudine empatic,onesti deschis n relaiile cu copiii.

Cuvinte cheie: psihosomatic, gastroenterologie, copil

REFERATE GENERALE

2

Bolile psihosomatice sunt acele afeciuni medi-cale a cror apariie i/sau evoluie este determinat,n mod semnificativ, de factori psihologici. Cu toatec, n principiu, orice afeciune este influenatntr-o oarecare msur de factorii psihologici, existun numr de afeciuni descrise n medicina psiho-somatic clasic, pentru care aceast legtur estedeterminant. (1)

Ideea c este imposibil s se despart sntateacorpului de cea a minii a fost exprimat nc detimpuriu n Cartea lui Iov. (2)

Platon a formulat acest punct de vedere nCharmides: Vindecarea multor boli este necunos-cut doctorilor Greciei, deoarece ei neglijeaz n-tregul, care trebuie, de asemenea, studiat, pentru cpartea nu se poate simi bine dac ntregul nu sesimte bine. (2)

Sunt bine cunoscute structurile contrastante alecolii lui Hipocrate din Kos, bazat pe concepiiledinamic, umoral i psihosomatic, precum i coaladin Knidos cu viziune mecanici organic.

C.G. Jung (2005) afirma c,,funcionri defec-tuoase ale sufletului pot duce la importante tulburri

ale corpului, dup cum, n mod reciproc, o afeciune

fizic poate antrena o suferin a sufletului. PentruC.G. Jung corpuli sufletul nu sunt principii dis-tincte, ci ele constituie mai curnd o singuri

aceeai via i, din acest motiv, rareori se n-tmpl ca o boalfizic s nu aib o complicaiemoral, precum i, n mod invers, o suferinfizics nu fie determinat de cauze psihice (3).

Pornind de la aceste prime intuiii, prin colabo-rarea dintre psihologi i medici, au fost identificaten timp o serie de boli la care factorul psihogen esteprevalent fie n debutul bolii, fie n meninerea ei,boli denumite psihosomatice. De fapt, termenul depsihosomatic, referindu-se la unitatea psyche soma, acoper actualmente un registru larg i hete-rogen de afeciuni: tulburrile somatoforme, factoripsihologici ce afecteaz o condiie medical gene-ral sau afeciunile psihosomatice.

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REVISTA ROMNDE PEDIATRIE VOLUMUL LXII, NR. 1, AN 201312

Reaciile psihosomatice apar n situaiile deo-sebit de stresante i dispar de obicei cnd nceteazsituaia care a declanat factorul determinant.

Tulburrile psihosomatice au caractere diferitei pot fi clasificate n urmtoarele grupuri:

Simptome de conversiune constau ntr-un

rspuns somatic secundari dezvoltarea unuiconflict nevrotic (ex: paralizia isteric, pares-tezia, orbirea, surditatea psihogen, vomis-mentele, senzaii de durere);Sindroamele funcionale implic tulburrifuncionale ale anumitor organe i sisteme,constituie sechele la o anumit funcie organicafectat;Tulburri psihosomatice se bazeaz peexistena unei reacii fizice, conflictual saude stres, nsoit de leziuni de esut demons-trate morfologic i de punerea n eviden aunor modificri organice. Afectarea unui or-gan este legat de o predispoziie. (ex: astmulbronic, colita ulcerativ, artrita reumatoid,ulcerul duodenal, anorexia).

Cercetarea psihosomatic a artat c emoiilejoac un rol semnificativ n apariia afeciunilorgastrointestinale i nutriionale i au o natur cutotul specific. Acestea sunt centrate n jurul aspi-raiei dup sigurani protecie. Pentru a le obine,

cei mai muli pacieni adopt o cale regresiv,urmnd un complex comportamental infantil. Foxconstat existena unui strns raport ntre tulburrilegastrointestinale i dezvoltarea emoional dinprima copilrie (4).

Muli copii nu sunt capabili s fac fa cerinelorla care sunt supui i apeleaz n condiii de stres lamecanisme de aprare regresive. Fondul expe-rienelor emoionale n afeciunile gastrointestinaleeste mai mult mascat dect explicitat: numai simp-tomele fizice rmn vizibile (5). Dac simptomul

sau organul vizat este n cele din urm vindecat prinmijloace medicale sau chirurgicale, atunci simpto-mele psihice ca anxietatea, depresia sau viciul, de-vin de obicei manifeste. (1)

Utiliznd o abordare fenomenologic, s-a consi-derat c unii factori emoionali sunt generatoriisimptomelor gastrointestinale la copil: dificultaten apucarea obiectelor (stomatit, afeciuni ale gin-giilor), dificultate n a nghii ceva (tulburri de de-glutiie), stri de dezgust sau repulsie (anorexie,

grea, vom, malnutriie), indigestie mintal cro-nic, dificultate de a stpni ceva (dispepsie, ente-rocolit, colon iritabil), incapacitatea de a se des-pri de ceva (constipaie cronic), dorina de ascpa de ceva (diaree cronic). (5)

Conflictul psihologic care modific semnificativfuncia somaticeste semnul distinctiv al tulburrilorpsihosomatice.Orice fel de stres emoional poate fiasociat cu orice tip de tulburare psihosomatic laun copil sau adolescent (6).

Principalele tulburri gastrointestinale la care

factorul psihosomatic este prevalent fie n debutulbolii, fie n meninerea lor, sunt: afeciunile gastro-duodenale, esofagitele corozive, constipaia, dia-

reea emoional, sindromul colonului iritabil, rec-

tocolita ulceroasi Boala Crohn.

Afeciunile gastroduodenaleGlatzel a descrisulceraia peptic ca fiind consecina anumitor si-tuaii de stres la persoane predispuse s reacionezeprin tulburri somatice ale tractului gastrointestinal,pe baza structurii personalitii i a experienei lorde via din trecut. (6,14)

Funciile gastrice, motricitatea, fluxul sanguin isecreia acid sunt strns legate de activitatea pro-ceselor nervoase suprapuse ca i destarea emoio-nal dominant. De exemplu, agresivitatea i resen-timentul accelereaz timpii digestiei, n timp ceanxietatea i emoiile puternice au un efect contrar.Pe de alt parte, anxietatea, dorina irealizabil de afugi, gndurile depresive determin hipoclorhidriei dismotilitate la nivel gastric. Anxietatea cronici strile conflictuale ce produc reacii ostile i ten-

dine agresive favorizeaz hiperaciditatea, iar dacpersist, produc modificri ale mucoasei, aa cumse ntmpl n gastrite (7).

Att tulburrile fizice, ct i cele psihice potproduce stri de anxietate care, la rndul lor, influ-eneaz sistemul nervos, dnd natere la spasm itensiune, ceea ce completeaz cercul vicios alsimptomelor. O mucoas care a suferit modificrin acest sens devine vulnerabil la leziuni, o traumuoar poate cauza o foarte mic eroziune cu evo-luie rapid spre ulcer.

Tipurilor active i pasive de pacieni cu ulcerduodenal li s-a acordat mult atenie n literatura despecialitate.

Dispoziia fundamental a tipului de pacienipasivi este depresia. Ulceraiile apar cnd dorinelecontiente sau incontiente legate de aceast de-penden sufer un eec. De prim importan lapacientul cu ulcer aparinnd tipului pasiv esteteama incontient de a pierde ngrijirea i proteciaoferite de mam. Este o fric ce duce la tensiune

constant. Orice ndoial, cum arfi

absena uneipriviri afectuoase, poate precipita anxietatea.Aceeai reacie poate totui sfie produs de teamade figura autoritar a tatlui. Strategia copiilor seconcentreaz pe dorina de a fi protejai. n general

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aceti pacieni provin din familii supraorganizate,cu o mam hiperprotectiv.

Tipul pacienilor hiperactivi se caracterizeazprin faptul c acetia ncearc s supun dorina lori continu s fie frustrai. Sunt persoane active,chiar agresive, care i asum rspunderi. Pentru

aceti pacieni, succesul este singura form desecuritate (7).Factorii psihogeni sunt deseori dificil de cuan-

tificat, dar portretul psihologic al unui copil ulcerosar include: personalitate introvertit, anxietate,

perfecionism i relaii minime familiale i sociale.Au mai fost citatestresulcolarimportant, precumi dispariia unuia din prini ntr-un interval de 12luni anterior apariiei ulcerului.

Pe de alt parte, stresul psihic ar putea fi implicati n alterarea rspunsului imun laH. pylori. Exist

studii care evideniaz o cretere a numrului deulcere diagnosticate n rndul populaiilor afectatede catastrofe naturale sau provocate de om. n acestsens, se pare c stresul emoional ar precipita apa-riia bolii la indivizii H. pylori pozitivi i arfavoriza dezvoltarea ulcerului la cei cu nivel sczutal infeciei sauH. pylori negativi (8,19).

Esofagitele corozive sunt ntlnite n special lacopilul de 1-3 ani care, accidental, ingereaz soluiede sod caustic (leie) n perioada cnd este cerce-ttor.

Sentimentul de culpabilitate al prinilor (ne-glijena) i spitalizrile lungi i repetate ale copiilor,la care se adaug agresivitatea manoperelor medi-cale instrumentale, sunt elemente care induc dis-funcii uneori profunde ale relaiei copilului cu fa-milia. Copilul devine trist, irascibil, introvertit, cudificulti de alimentaie i reintegrare familial.Apar tulburri de somn. Pe lng aceste manifestripsiho-somatice, se adaug i denutriia legat dedificultatea de alimentare, anemia carenial (9).

n funcie de circumstanele n care au avut locintoxicaiile, tririle psihologice pot fi: sentimentulde vinovie, autonvinovire, sentiment de revolt,aparena nedreptii, negaie mental retroactiv,frica generalizat pentru urmri i pentru posibilerepetri chiar incontiente, ajungndu-se astfel lastri de anxietate. Gastroenterologii apreciaz c oabordare psihosomatic a acestor disfuncii estepozitiv n planul terapeutic. Rolul psihologului ideseori al psihiatrului este esenial. O apropiere depacient, de psihismul su, contribuie la efectele me-

dicaiei sau manevrelor medicale corectoare (4).Constipaia cronic este o afeciune frecventi

larg rspndit. Apare de obicei la pacienii anxioii deprimai, introvertii (9). Constipaia la copilulmic capt o component psihic indus de durerea

la defecaie. Copilul amn momentul i evoluia seface ctre encompresis, astfel nct apare un cercvicios ce agraveaz simptomatologia.

n literatur sunt citate urmtoarele corelaii psi-hosomatice cu constipaia cronic: reacia de pro-test, ncercarea de retenie, reinerea anxioas, an-

xietatea i aprarea n faa unor situaii dificile. (10)Constipaia n prima copilrie trebuie privit ca oreacie de protest, n particular mpotriva instruiriiexagerate pentru nsuirea deprinderilor igienice.

Encompresisul estepredominant la sexul mas-culin iafecteaz1% dintrecopiii n vrstde 5 ani.Este mai frecvent observat la cei care provin dinmedii socio-economice defavorizate. Substratul or-ganic este rareori gsit (9). Afeciunea indic o tul-burare emoional serioasi este adesea asociatcu constipaia cronic sau megacolon psihogen.Frecvena i performana colar pot fi afectate,deoarece copilul devine inta dispreului colegilor.Simptomele necesit frecvent intervenia psiho-terapeutic asupra copilului i familiei.

Diareea emoional este una dintre cele maintlnite tulburri funcionale ale intestinului. Esteasociat cu hipermotilitatea colonului i const ntulburri de tranzit intestinal. Modificrile pot fi n-soite de perturbri autonome atipice. Cauzele defond ale crizelor sunt de obicei situaiile produc-

toare de nelinite i suprancordare (10).Personali-tatea copilului pare sfie marcat de frica de auto-ritate i de un sentiment de dependen neajutorat.Impresia de a fi supus unor cerine excesive, altu-rat sentimentului de slbiciune, sunt compensatede o dorin exagerat de preuire i de succes.

Sindromul colonului iritabil peste jumtatedin pacienii cu aceast afeciune se adreseaz me-dicului din cauza simptomatologiei digestive cu uncaracter complex, caracterizat prin dureri difuze,colicative, alternan ntre constipaie i diaree, me-

teorism. Toate simptomele pot fi agravate de situaiiemoionale i de stres. Diagnosticul pozitiv este ngeneral unul de excludere. (11)Profilul personalitiiacestor pacieni este neomogen, dei pare s induco tendin ctre transformarea obsesiv-compulsiva tririlor emoionale cnd exist o structur desubstrat depresiv. A fost remarcat, de asemenea,nivelul ridicat de anxietate la aceti pacieni. (11).

Rectocolita ulcerativi Boala Crohn evoluiaacestor entiti poatefi sever, cu episoade de re-

misiune alternnd cu perioade de acutizare. Etio-logia ambelor afeciuni nu este clar, dei cauzelebacteriene, virale i imunologice sugereaz caceste boli sunt variante ale unor procese comunefiziopatologice fundamentale.

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Pacienii provin de obicei din familii cu relaiistructurate simbiotic, n care sentimentele sunt rardiscutate. Stima de sine este slab, iar copiii suntfoarte sensibili la eec. Caracteristic acestor pacienisunt infantilismul, reaciile depresive, narcisismuli agresiunea inhibat. Le lipsete experiena i

comportarea agresiv contient. Bolnavii i reducorice form de afectivitate i, n consecin, suntincapabili s fac fa pierderilor sau despririlor.

S-a emis ipoteza c pacienii cu boal Crohn potfi deosebii de cei cu colit ulcerativ prin conside-raii fenomenologice (4). n timp ce copiii cu rec-tocolit prsesc mediul familial relativ trziu imenin structura simbiotic a relaiilor, cei cu boalaCrohn au tendina s se despart de prini la vrstetimpurii i demonstreaz o capacitate apreciabilde introspecie. Ambele tipuri de pacieni evit dis-

putele i sunt incapabili s-i stpneasc senti-mentele (12).

Impactul general al bolii este adesea reflectat nprezena copilului i performana la coali acti-vitile extracuriculare. n evaluarea clinic aacestor pacieni o atenie deosebit trebuie acordatstatusului lor psihologic. Dei problemele emoio-nale nu determin niciodat o influen directasupra cursului afeciunii, ele exacerbeaz n modclar simptomele copilului (12). Psihoterapia de sus-inere este necesar pentru completarea medicaiei.Aceti copii suport spitalizri repetate, tratamentecronice medicamentoase cu efecte adverse siste-mice, regim igieno-dietetic special ce nu le permites se integreze normal n colectiviti. Condiia ge-neral a pacientului este nesatisfctoare, iar atitu-dinea este regresiv.

Baza dialogului de consolidare a relaiei medic-pacient este audierea atent, sftuirea activ. Dincauza puternicei lor nevoi de autonomie, pacieniicu boal Crohn par s resping sau s ntrerup

tratamentul mai mult dect cei cu colit ulcerativ.Colaborarea medicinei interne cu psihoterapia pares prelungeasc perioadele dintre recidive, s scur-teze episoadele de exacerbare, s reduc durerile isfie util reintegrrii sociale a pacientului (13).

n faa unui pacient psihosomatic este necesar caatitudinea terapeutic s nceap prin ascultareatent, concentrare i acompaniere n relatarea su-ferinei sale.

Acompanierea empatic crete rezonana pa-cientului la terapie i l mobilizeaz n procesul de

refacere, resemnificare, reevaluare a tririlor salepsihologice (8).

Pornind de la premiza c n fiecare persoanexist o funcie sanogenetic care ateapt sfiereactivat, la copil, comparativ cu adultul, aceast

funcie poate fi mai uor accesat prin faptul c re-zistenele i mecanismele lor de aprare nu suntfoarte puternice. Copilul trebuie s primeascsuport emoional i sfie ajutat s i neleag sen-timentele fa de situaia de boal traversat. Me-dicul trebuie s realizeze o relaie de ncredere, s

dezvolte o atitudine empatic, onesti deschis nrelaiile cu copiii (7).Cele mai importante obiective terapeutice ur-

mrite de medic/psiholog sunt cele viznd: redu-cerea anxietii, depresiei i, n general, a afectelornegative; facilitarea contientizrii i a exprimriipropriilor afecte, mbogirea vieii imaginative,diferenierea senzaiilor de sentimente; ameliorareafuncionrii personale i autonomiei, n ciuda boliisomatice; ameliorarea relaionrii n familie, grupsocial, grup profesional diminuarea afectelor ne-

gative acumulate; ameliorarea imaginii de sine, in-clusiv a imaginii corporale; modificarea compor-tamentelor nefavorabile sntii; restructurareacogniiilor eronate generatoare ale acestor compor-tamente. (14)

La pacienii psihosomatici i-au dovedit eficienai tehnicile de biofeedbacki cele de relaxare ncreterea strii de bine corporale i n diminuareaanxietii (14). Este necesar s se acioneze ,,de lacaz la caz n ceea ce privete metodele psihote-rapeutice utilizate, lundu-se n considerare tipulde personalitate a bolnavului, factorii psihotrau-matizani i circumstanele n care s-a dezvoltatafeciunea respectiv (15,16).

Activitatea psihoterapeutic trebuie sfie binecondus, dup un program riguros respectat. e-dinele nu trebuie sfie obositoare, ci s aib carac-terul de stimulent pentru bolnav. Nu sunt vizate,,simptomele somatice, ci factorii conflictuali,frustrrile i complexele ideoafective (17,18).

Intervenia psihoterapeutic trebuie dublat, cel

puin n etapa de debut, de cea medicamentoaspropus de medicul specialist. O intervenie me-dical eficientpoate duce la reducerea simptomelordisfuncionale pentru ca, apoi, psihoterapia s per-mit diminuarea sau eliminarea cauzelor psihogenei consolidarea strii de sntate. (17,18)

Numai o abordare interdisciplinar, obinutprin colaborarea dintre medic, psiholog i psihiatru,poate asigura succesul pe termen lung n tratamentultulburrilor gastrointestinale cu fond psihosomaticla copii.

CONCLUZII

Conflictul psihologic care modific semnificativfuncia somaticeste semnul distinctiv al tulburrilor

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psihosomatice.Orice fel de stres emoional poate fiasociat cu orice tip de tulburare psihosomatic laun copil sau adolescent. Tulburrile gastrointestinalese asociaz cu trsturi regresive pronunate, stricare au prezentat o cretere vizibil n ultimii ani.Dac simptomul sau organul vizat este n cele din

urm vindecat prin mijloace medicale sau chirur-gicale, simptomele psihice ca anxietatea, depresiasau viciul devin de obicei manifeste, astfel nctrolul psihologului i deseori al psihiatrului esteesenial.

Psychosomatic approaches to digestive diseases in children

Ana-Maria Ciubara1, Gabriela Pduraru2, Ancua Ignat2, Amalia Constantin2,Smaranda Diaconescu2, V.V. Lupu2, M. Burlea2

1

Department of Psychiatry, Gr. T. Popa University of Medicine and Pharmacy,Romania;Socola Clinical Psychiatric Hospital, Iasi2Pediatrics Department, UMF Gr. T. Popa, V-th Clinic of Pediatrics,St. Mary

Clinical Emergency Childrens Hospital, Iasi

ABSTRACT

Psychosomatic diseases refer to those medical affections whose appearance and/or evolution is significantly

influenced by psychological factors. The main digestive disorders in which the psychosomatic factor is prevalent

are: gastroduodenal affections, corrosive esophagitis, constipation, encopresis, emotional diarrhoea, irritable

bowel syndrome, ulcerative rectocolitis and Crohns disease. The management is based on collaborationbetween the psychologist and the pediatric gastroenterologist. Supportive psychotherapy is necessary for

completing medication. Child should receive emotional support and be helped to understand their feelings

about the situation of the disease. The doctor must create a relationship based on trust, develop an attitude that

shows empathy, honesty and openness towards children.

Key words: psychosomatic, gastroenterology, child

Psychosomatic diseases refer to those medicalaffections whose appearance and/or evolution issignificantly influenced by psychological factors.Although, in principle, any disease is influenced tosome extent by psychological factors, there are anumber of conditions described in classical psycho-somatic medicine, for which this connection isessential.(1)

The idea that it is impossible to separate thehealth of the body from that of the mind was ex-pressed very early in the Book of Iov. (2)

Plato also formulated this point of view in Char-mides: The cure of many diseases is unknown to

the physicians of Hellas, because they are ignorantof the whole, which ought to be studied also; for thepart can never be well unless the whole is.(2)

The contrasting structures of the HippocraticSchool of Kos are well known, based on dynamic

concepts, humoral and psychosomatic and KnidosSchool with mechanical and organic vision.

C.G. Jung (2005) stated that the imperfect func-tioning of the soul may lead to significant disorders

of the body just as, reciprocally, a physical affection

may entail an ailment of the soul. For C. G .Jungthe body and the soul are not distinct principles,

but represent the one and the same life and, as aresult, it rarely occurs that a physical disease is notaccompanied by a moral complication, and con-versely, a physical suffering is often determined bypsychic causes.(3)

Starting from these preliminary intuitions,

through the cooperation of psychologists and phy-sicians, a series of diseases was identified for whichthe psychogenic factor prevails, either at the be-ginning of the disease, or throughout its evolution.These diseases are known as psychosomatic dis-

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eases. In fact, the termpsychosomatic, referring tothe psyche-soma unity, actually covers a broad andheterogeneous range of affections: somatoform dis-orders, psychological factors affecting a generalmedical condition or psychosomatic affections.Psychosomatic reactions occur in very stressful

situations and usually disappear when the situationthat triggered the determining factor ends.Psychosomatic disorders have different charac-

ters and can be classified into the followinggroups:

Conversion symptoms1. consist of a second-ary somatic response and the development ofa neurotic conflict (eg: hysterical paralysis,paresthesia, blindness, psychogenic deaf-ness, vomiting, sensations of pain);

Functional syndromes2. involve functional

disorders of certain organs and systems, aresequels to an organic affected function;

Psychosomatic disorders3. are based on aphysical, conflicting or stress-triggered reac-tion, accompanied by tissue lesions, demons-trated morphologically, and by the highligh-ting of organic changes. Organ damage isrelated to a predisposition (eg: asthma, ul-cerative colitis, rheumatoid arthritis, duode-nal ulcer, anorexia).

Psychosomatic research has shown that emoti-ons play a significant role in the appearance ofgastrointestinal and nutritional affections, and havespecific characteristics. These are centered on theneed for safety and protection, and in order to obta-in them, the vast majority of patients adopt a re-gressive path, following an infantile behaviouralcomplex. Fox observes the existence of a tight rela-tion between gastrointestinal disorders and theemotional development of the first childhood.(4)

Many children are not capable of coping with

what they are required to do and rely, under stressconditions, to regressive defence mechanisms. Thestock of emotional experiences in gastrointestinalaffections is much more hidden than explained:only the physical symptoms remain visible.(5) Ifthe envisaged symptom or organ is finally cured bymedical or surgical means, then psychic symptomssuch as anxiety, depression or vice usually becomeevident.(1)

By using a phenomenological approach, it wasconsidered that a series of emotional factors ge-

nerate the childs gastrointestinal symptoms: dif-ficulty in grasping objects (stomatitis, affections ofthe gums), difficulty in swallowing (deglutitiondisorders), states of disgust or repulsion (anorexia,nausea, vomiting, malnutrition), chronic mental in-

digestion, difficulty in mastering something (dys-pepsia, coloenteritis, irritable bowel), the incapaci-ty to separate from something (chronic constipation),the desire to get rid of something (chronic diarrhea).(5)

The psychological conflict significantly altering

the somatic function is the distinctive sign ofpsychosomatic disorders. Any form of emotionalstress may be associated to any type of psychoso-matic disorder in a child or teenager.(6)

As follows, we shall briefly describe the maingastrointestinal disorders where the psychosomaticfactor prevails either in the debut of the diseasethroughout its evolution, namely in: gastroduode-nal affections, corrosive esophagitis, constipation,emotional diarrhea, irritable bowel syndrome, ulce-rous recto-colitis and Crohns Disease.

Gastroduodenal affectionsGlatzel describedpeptic ulceration as being the consequence of par-ticular stressful situations in persons predisposed toreact through somatic disorders of the gastrointesti-nal tract, on the basis of their personality and pastlife experience. (6,14)

The gastric functions, motility, blood flux andacid secretion are intimately related both to the ac-tivity of the overlapped nervous processes and tothe dominant emotional state. For instance, aggres-siveness and hard feelings accelerate the passage offood through the stomach, whereas anxiety andstrong emotions produce pyloric spasm and slowits passage. On the other hand, anxiety, the irresis-tible desire to escape, depressive thoughts reducechloride acid secretion, the motility and blood af-flux of the stomach. Moreover, chronic anxiety andstates of conflict producing hostile reactions andaggressive tendencies increase gastric acid se-cretion, and if persistent, produce alterations of themucous membrane, as in gastritis. (7)

Both genuine and imaginary disorders may pro-duce states of anxiety which in their turn influencethe nervous system, producing spasm and tension,thus completing the vicious circle of symptoms. Amucous membrane that suffered alterations in thisrespect becomes vulnerable to lesions; a slight tra-uma may cause very small erosion, which, throughcontact with the gastric juices may lead to the for-mation of ulcer.

Active and passive types of patients with duo-denal ulcer have been dealt with extensively in the

specialised literature.Depression is the fundamental state of being of

thepassive type of patient. Ulcerations appear whenconscious or unconscious desires related to this de-pendency fail. Of outmost importance for the passi-

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ve type patient is the unconscious fear of losing thecare and protection provided by the mother. It is afear leading to constant tension. Any doubt, such asthe absence of an affectionate look, may precipitateanxiety. Nevertheless, the same reaction may be ca-used by the fathers patriarchal authoritarianfigure.

All their strategy concentrates on the desire to beprotected. Generally speaking, these patients origi-nate from super-organized families, with a hyper-protective mother. They are led by the need for pro-tective love even with regard to the choice of a lifepartner. Male teenagers displaying this type of ul-cer often look for a motherfigure in their girlfri-end.

The type of hyperactive patients is characterizedby the fact that they try to repress their desires andthus continue to be frustrated. They are active per-

sons, even aggressive, they take responsibilities.For these patients, success is the only form of secu-rity. (7)

Psychogenic factors are sometimes difficult toquantify, but the psychological portrait of an ulce-rous child would include: introverted personality,anxiety, perfectionism and minimal familial andsocial relations. Significant school stress as well asthe disappearance of one of the parents was quotedwithin a period of 12 months before the appearanceof the ulcer.

On the other hand, psychic stress may be in-volved in the alteration of the immune response to

H. pylori. There are studies highlighting an increa-se of the number of ulcers diagnosed at the popula-tions affected by natural or man-made catastrophes.In this respect, it seems that emotional stress mayprecipitate the appearance of the disease inH. py-lori positive individuals and would favour the de-velopment of ulcer at those with a decreased levelof the infection orH. pylori - negative. (8, 19)

Corrosive esophagites are met in the 1 to 3 year-old child, who accidentally swallows caustic sodasolution (lye wash) during the time when they are asearcher.

The parents feeling of guilt (negligence) andthe childrens long and repeated hospitalizations,accompanied by the aggressiveness of the medicalinterventions are elements that sometimes induceprofound dysfunctions in the childs relationshipwith his family. The child becomes sad, irascible,introverted, revealing nutrition and familial rein-

tegration difficulties. To these psychosomatic mani-festations, one may add denutrition related to theeating difficulty, deficiency-based anaemia. (9)

Depending on the circumstances in which into-xications occur, psychological experiences may fall

into the following categories: the feeling of guilt,self-condemnation, the feeling of rebellion, a senseof injustice, retroactive mental negation, generali-zed fear of consequences and of unconscious repe-titions, thus leading to states of anxiety. Gastroen-terologists believe that a psychosomatic approach

to these dysfunctions is positive so far as treatmentis concerned. The psychologists, and often the psy-chiatrists role is essential. Close contact with thepatient and with their psyche may often be an effec-tive corrective medical manoeuvre. (4)

Chronic constipation is a frequent and wides-pread affection. It usually appears at anxious or de-pressed patients who seem careless, but are, as amatter of fact, tense. (9)

Constipation in the 1 to 4 year-old child acquiresa psychic dimension induced by the pain upon de-fecation. The child postpones the moment of de-fecation which leads to encopresis and to a viciouscircle, because the child is afraid to defecate due tothe pain, which aggravates the symptomatology.

The specialised literature mentions the followingpsychosomatic correlations with chronic constipa-tion: reaction of protest, attempt at retention, anxi-ous retention, anxiety and defence when confrontedwith a series of difficult situations.(10) Constipati-on during early childhood must be regarded as a

reaction of protest, particularly against the exagge-rated teachings to acquire hygienic skills.Encopresis is predominant in males and affects

1% of 5-year old children. It is more frequently ob-served in children from disadvantaged socio-eco-nomic backgrounds. Organic underlying conditionsare rarely found. (9) Encopresis indicates a severeemotional disorder. It is often associated with chro-nic constipation or psychogenic mega-colon. Scho-ol attendance and performance may be affected be-cause the child becomes the target of his/her peers

derisions. The symptoms frequently require thepsychotherapeutic treatment of the child and theirfamily.

Emotional diarrhea is one of the most frequentfunctional disorders of the intestines. It is associa-ted with the hyper-motility of the colon and con-sists in the alternation of diarrhoea and constipati-on. The disorder may be accompanied by atypicalautonomous perturbations. The background causesof the crises are usually the situations producing

anxiety and over tenseness. (10) The childs perso-nality seems to be marked by the fear of authorityand by a feeling of helpless dependency. The im-pression of being subject to a series of excessiverequests, accompanied by the feeling of weakness,

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is compensated by an exaggerated desire for appre-ciation and success.

Irritable colon syndrome more than half ofthe patients with this affection refer to the physici-an as a result of the digestive symptoms that arecomplex in nature and characterized by diffuse,

colicative pains, alternation of episodes of consti-pation and diarrhoea, meteorism. All symptomsmay be worsened by emotional and stressful situa-tions. The positive diagnosis is generally one of ex-clusion.(11) The personality profile of these pati-ents is not homogenous, although it seems toindicate a tendency towards the obsessive-compul-sive transformation of emotional experiences whenthere is a depressive disposition. An increased levelof anxiety was also noticed in these patients. (11)

Ulcerative colitis and Crohns Disease the

evolution of these inflammatory diseases may besevere with episodes of remission alternating withepisodes of acutisation. The aetiology of both di-seases is not clear, although bacterial, viral and im-munological causes suggest that they are variantsof a series of common fundamental physical patho-logical processes.

The patients usually come from families withsymbiotically structured relationships, where fee-lings are rarely discussed. Self-esteem is weak andthey are extremely sensitive to failure. These pa-tients are characterized by infantilism, depressivereactions, narcissism and inhibited aggression.They lack experience and conscious aggressiveconduct. Patients reduce any form of affectivityand are consequently incapable to cope with lossesor break-ups.

There is a hypothesis according to which pati-ents with Crohns disease may be distinguishedfrom patients with ulcerative colitis, by means ofphenomenological considerations. (4) While chil-

dren with rectocolitis leave their familial environ-ment relatively late and maintain the symbioticstructure of relationships, those with Crohns disea-se tend to separate from their parents at an early ageand demonstrate a notable capacity of introspecti-on. Both types of patients avoid disputes and areincapable to restrain their feelings. (12) The overallimpact of the disease is often reflected in the childspresence and performance in school and extracurri-cular activities. In the clinical evaluation of thesepatients, consideration should be given to their psy-

chological status. Although emotional problemsnever cause nor directly affect the course of the di-sease, they clearly exacerbate the childs symptoms.(12) Supportive psychotherapy is necessary forcompleting medication. These children undergo re-

peated hospitalizations, chronic medication withsystemic side effects, and a hygienic - dietary regi-me which do not allow them to integrate themsele-ves into their communities. The patients generalcondition is not satisfactory, and their attitude is re-gressive.

The basis of the dialogue to consolidate the doc-tor-patient relationship is represented by the carefullistening and activecounselling. Because of theirstrong needs for autonomy, patients with Crohnsdisease seem to reject or discontinue the treatmentmore than those with ulcerative colitis. The colla-boration between internal medicine and psycho-therapy seems to extend the periods between relap-ses, shorten episodes of exacerbation, reduce painand be useful to the social reintegration of the pati-ent.(13)

When treating a psychosomatic patient, the the-rapeutic approach ought to begin by careful lis-tening, concentration and empathy with the accountof their suffering.

Empathic accompaniment increases the pa-tients response to therapy and supports him in theprocess of recovery, re-signification, re-evaluationof his inner psychological experiences and feelings.(8) Starting from the premise that each person has asanogenetic function waiting to be reactivated, inchildren, unlike in adults, this function may be ea-

sily accessed due to the fact that resistances andtheir defence mechanisms are not that strong. Ac-cordingly, the child must receive emotional supportand must be helped to understand his/her feelingstowards the type of disease experienced. The physi-cian has to establish a trustful relationship, to deve-lop an empathic, honest and opened attitude in hisor her interactions with children.(7)

The most important therapeutic objectives pur-sued by the physician/psychologist are: to reduceanxiety, depression and, in general, negative affects;

to facilitate self-awareness and the voicing of theirown feelings, to enrich imaginative life, to distin-guish sensations from feelings; to improve personalfunctioniong and autonomy in spite of the somaticdisease; to improve family, social and professionalrelationships to reduce the cumulated negative af-fects; to improve self-perception, including the per-ception pertaining to bodily image; to alter beha-viours detrimental to health; to restructure theerroneous cognitions generating these behaviours.(14)

In psychosomatic patients, the techniques ofbiofeedback and the relaxation techniques provedtheir efficiency in increasing the patients goodbodily state and in reducing anxiety. (14) It is ne-cessary to act on a case-by-case basis, with regard

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to the psychotherapeutic methods used. One shouldtake into account the psycho-traumatic factors andthe circumstances in which the respective affectiondeveloped. (15, 16)

The psychotherapeutic activity must be con-ducted according to a rigorously observed sched-

ule. Meetings must not be tiring but stimulating forthe patient. It is not the somatic symptoms thatare targeted, but rather the factors generating con-flict, the patients frustrations and their idea-affec-tive complexes. (17, 18).

The psychotherapeutic intervention must be ac-companied, at least in the initial stage, by the drugtherapeutic scheme set forward by the consultant.An efficient medical intervention may lead to thereduction in dysfunctional symptoms, to the de-crease or elimination of physiological causes, so

that, afterwards, psychotherapy may permit the re-duction or elimination of the psychogenic causes,and the consolidation of the health condition. (17,18)

Only an interdisciplinary approach achievedthrough the cooperation between the physician andthe psychologist may ensure the long-term successin the treatment of childrens gastrointestinal psy-chosomatic disorders.

CONCLUSIONS

Psychological conflict which significantly alterssomatic function is the hallmark of psychosomaticdisorders. Any emotional stress may be associatedwith any type of psychosomatic disorder in a childor adolescent. Gastrointestinal disorders are asso-ciated with pronounced regressive traits, conditionsthat have increased visibly in recent years. If thesymptom or the body concerned is finally cured bymedical or surgical means, psychiatric symptoms

like anxiety, depression or addiction usually be-come manifest, so that the role of the psychologistor of the psychiatrist is often essential.

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