As in the irritable bowel syndrome, may emotional factors modify pain perception in the nutcracker esophagus ? Should these patients be given psychotropic treatments ?
J.E. Richter (Birmingham)
Several studies have shown that patients with the nutcracker esophagus tend to have excessive concern about somatic function, have more frequent severe gastrointestinal symptoms under stress, and have a high prevalence of psychiatric diagnoses such as depression, anxiety, somatization disorders and panic attacks [ 1, 2]. Unfortunately, like the proverbial chicken and egg analogy, we do not know whether chronic chest pain causes psychologic abnormalities or the reverse is true.
Furthermore, the patients studied to date have been referred to major medical centers for further evaluation. As observed in patients with irritable bowel syndrome, the high frequency of psychological disturbances may be primarily related to health care seeking behavior rather than the motility disorders [3]. Despite these uncertainties, it appears that emotional factors may modify pain perception in patients with the nutcracker esophagus.
The mechanism contributing to modified pain perception is uncertain but studies have shown that conditioning can improve the perception of stimuli from internal organs so that a person may perceive physiologic changes he was not aware of previously [4]. The habitual practice of «selective perception» and «selective attention » to a part of one's body, motivated by the fear of having an important disease such as heart disease, is likely to improve a person's skill in detecting bodily changes. Both anxiety and depression serves as a motive for selective perception. The patient becomes progressively more anxious, which leads to more somatic symptoms, which in turn leads to more anxiety, more selective perception, and a vicious cycle is established. Therefore, breaking the cycle may require the use of psychotropic drugs regardless of whether the psychiatric diagnosis is a primary or secondary disorder.
Anecdotal reports have suggested that sedatives or tranquillizers may be effective in patients who had a definite stress relation to the precipitation of their symptomatic esophageal motility disorders. A recent report seems to substantiate these observations. In a six week, double-blind placebo controlled parallel trial of trazodone (100-150 mg/ day) [5], Clouse et al. studied 29 patients with esophageal symptoms and distal esophageal motility abnormalities. Measurements of esophageal and psychologic symptoms were completed at entry and at each of two follow-up visits. Esophageal manometry was repeated at the termination of the trial.
On completion of treatment, patients receiving trazodone (N = 15) reported a significantly greater global improvement than those receiving placebo (N = 14;
P = 0.02). Although a variable clinical response was observed, the trazodone group had less residual distress over esophageal symptoms compared with the placebo group (59% ±9% vs. 108 % ± 19 %, P = 0.03). Manometric changes observed during the course of the trial were not influenced by treatment nor by clinical response. Remarkable reductions in ratings of chest pain were reported by both treatment groups, emphasizing the importance of controlled trials when studying this population. It is interesting to note, that this is the only placebo controlled study reported in the peer reviewed literature showing efficacy of any type of drug in the treatment of symptomatic painful esophageal motility disorders.
Though not studied in a controlled fashion, investigators also have reported symptomatic improvement with other psychotropic drugs including amitriptyline, imipramine and busipirone. Behavior modification programs and biofeedback may also be beneficial in the long term management of these patients.
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