The largest case series of functional abdominal bloating is still Alvarez's unfortunately titled “hysterical type of nongaseous abdominal bloating
]. His article began thus, “In 1911, I saw a psychopathic woman, past the menopause, who, with her protuberant abdomen, was sure she was pregnant by the Holy Spirit... I learned then that a bloated abdomen can be produced purely by nervous means.” Perhaps we can forgive his generalization, considering that it was the age of psychosomatic explanations for peptic ulcers and ulcerative colitis.
Unfortunately it has too often been the habit of physicians to blame the patient's psyche for symptoms the physician cannot explain. Let us state categorically that the average functional bloater is not crazy or faking it! Some years ago my colleagues and I found that patients who had a consultation with a gastroenterologist for the primary complaint of unexplained visible abdominal bloating had the same degree of anxiety or depression and even a greater tolerance to pain as patients with quiescent Crohn's disease [28
]. And as for faking it, voluntary protrusion of the abdomen has a different CT appearance than spontaneous bloating and CT scans and lateral abdominal films have shown that women with IBS and abdominal bloating have a normal degree of lordosis and a normally positioned diaphragm [30
]. Although recently the involuntary position of the diaphragm has been readdressed, it appears that as the abdominal contents sag downward and outward the diaphragm contracts rather than relaxes into a lower position, so-called abdomino-phrenic dyssynergia [4
]. The ancient observation that general anesthesia almost instantly relieves distention may now have an explanation—the diaphragm relaxes.
However, bloating is an extremely common symptom in apparently psychiatric conditions like anorexia nervosa, bulimia, and the somatization disorder. It is also true that persons who have experienced and survived extreme stresses such as the Nazi Holocaust frequently suffer from bloating [31
]. Bloating, stress, anxiety, and depression may coexist with or aggravate functional disturbances such as the irritable bowel syndrome or functional dyspepsia. In two large population surveys bloating correlated with psychiatric dysfunction: depression, sleeping difficulties, problems of coping, panic disorder, and agoraphobia [32
]. However bloating is also a common symptom in healthy and normally noncomplaining persons, even runners and athletes [34
]. So even though many patients find that their bloating is worse when they are anxious or it correlates with depression, insomnia, difficulty in coping, or alcohol abuse, I do not think we should “reflexly” blame the psyche. A symptom may cause psychic distress. Psychic distress may take the patient to the physician but we should not assume that the psyche is the cause of the symptom.