Psychological Factors Affecting Medical Condition

and Psychosomatic Medicine

Norieta C. Balderrama, M.D. FPPA

Adult Psychiatry

Child and Adolescent Psychiatry

Forensic Psychiatry

Reference • Kaplan’s and Sadock’s Synopsis of

Psychiatry chapter 28 pages 822-850

Outline • I. Overview • Definitions Stress Theory • II. Specific Disorders Gastrointestinal system Cardiovascular system Respiratory System Endocrine system Musculoskeletal System Psycho-oncology

Outline • III. Treatment of Psychosomatic

Disorders

• IV. Consultation Liaision Psychiatry

Overview • Psychosomatic medicine - unity of mind

and body

• Psychological factors are important in the development of disease

Definitions • Behavioral Medicine - • “ interdisciplinary field concerned with the

development and and integration of behavioral and and biomedical science knowledge and techniques relevant to health and illness and the application of this knowledge and these techniques to prevention , diagnosis and rehabilitation”

DSM IV -TR • Uses psychological factors affecting medical

condition instead of psychosomatic medicine • “ one or more psychological or behavioral

problems that adversely and significantly affect the course or outcome of a general medical condition, or that significantly increase a person’s risk of an adverse outcome”

Classification

• A. A general medical condition is present • B. Psychological factors adversely affect the

general medical condition in one of the following ways:

• 1. The factors have influenced the course of the general medical condition as shown by close temporal association between psychological factors and development or exacerbation of or delayed recovery from GMC

DSM • 2. Factors interfere with the treatment of the

general medical condition. • 3. The factors constitute additional health

risks for the individual• 4. Stress related physiological responses

precipitate or exacerbate symptoms of the general medical condition. Ex. Major depressive disorder delaying recovery from myocardial infarction; depressive symptoms delaying recovery from surgery

Exclusions • Classic mental disorders that have physical

symptoms - ex. Conversion disorder • Somatization disorder - physical symptoms

not based on organic pathology • Hypochondriasis - exaggerated concern for

health • Physical complaints associated with mental

illness like dysthymia • Physical complaints associated with

substance related disorders

History • Psychosomatic medicine dates back to

ancient beliefs

• Psychoanalytic - Sigmund Freud

• Psychophysiological - Walter Canon

• Sociocultural - Karen Horney

• Systems theory - Adolf Meyer

Stress theory • Walter Canon - first systematic study of

relation of stress to disease

• Harold Wolf - physiology of gastrointestinal tract appeared to correlate with specific emotional states

• Hans Selye ( 1907- 1982 )

• General adaptation syndrome

General Adaptation Syndrome

• Phases

• 1. Alarm reaction

• 2. Stage of resistance - adaptation is ideally achieved

• 3. Stage of exhaustion - acquired adaptation or resistance may be lost

Definition • Stress - non specific bodily response to any

demand caused by either pleasant or unpleasant conditions

• Distress- unpleasant • Stress may occur over long periods of time.

Neuroendocrine and immune responses may help explain why and how stress may have deleterious effects

Neurotransmitters • Stressors activate the noradrenergic system • ( in the locus ceruleus ) and cause release of

catecholamines from the autonomic nervous system. Stressors also activate the serotonergic systems ( increased turnover of serotonin )

• Glucocorticoids may increase serotonin 5Ht2 mediated actions contributing to intensification of of receptors - implicated in pathophysiology of major depressive disorder

Endocrine response to stress

• In response to stress - Corticotropin -releasing factor (CRF ) is secreted from the hypothalamus into the hypophysial-pituitary portal system. CRF ---> release of glucocorticoids promoting energy, increase cardiovascular activity, inhibiting functions such as growth, reproduction, and immunity

Immune response to stress • Part of stress response consists of

inhibition of immune functioning by glucocorticoids. It can also cause immune activation which can also self limit the immune activation

Social readjustment scale • Thomas Holmes and Richard Rahe • Rank relative degree of adjustment

required by life events • Death of spouse - 100 life change units • Divorce / ( translated to annulment ) -

73 units • Marital separation - 65 units • Death of close family member - 63 units

Specific Disorders • Gastrointestinal system - link between stress,

anxiety, physiological response of gastrointestinal system

• Enteric system sensitive to emotional states ex. Esophagus, acute stress increases resting tone of the upper esophageal sphincter and increases contraction amplitude in the distal esophagus- globus or esophageal spasm syndrome.

Gastrointestinal • Contraction abnormalities and functional

esophageal syndromes demonstrate high rates of psychiatric co-morbidity

• Anxiety disorders ranked high in a study of psychiatric co morbidities

• Anxiety disorders may induce physiological changes in the esophagus that can produce functional esophageal symptoms

Gastro esophageal reflux disease

• GERD - most common disorder of esophagus , accounts for over the counter

antacid consumption • Heartburn with regurgitation and pain • Psychological distress increases symptom

severity in patients prone to disease; study of GERD patients, excessive stress, too much excitement , family arguments , and temporary depression were felt trigger symptoms

Peptic Ulcer disease • Mucosal ulceration of distal stomach or

proximal duodenum ; gnawing or burning epigastric pain , 1-3 hours after meals with nausea, vomiting, dyspepsia, or GIT bleeding

• Psychosocial factors are involved in the clinical expression of symptoms , possibly reducing immune responses , resulting in vulnerability to H. pylori infection

Crohn’s disease • Inflammatory bowel disease affecting

small intestine and colon. Diarrhea, abdominal pain, and weight loss.

• Study of psyhciatric symptoms in Crohn’s disease prior to the onset of physical symptoms found high rates

( 23 percent) of pre existing panic disorder

Psychiatric Adverse Effects Associated with Drugs

• histamine receptor antagonists- famotidine, cimetidine, ranitidine - increase blood levels of tricyclic and SSRIs

• Proton pump inhibitor - omeprazole - increase carbamazepine concentration

• GIT stimulant - metoclopramide, can cause depression, dystonia, parkinsonism

• Others, antiemetics, antiinfective agents - especially interaction with lithium can be nephrotoxic

Cardiovascular system • Coronary heart disease - leading cause of

death ( US) about 1/3 of all adults over 35 will ultimately die of cardiovascular disease.

• Psychiatric disorders frequently occur as complications or comorbid conditions

• Autonomic cardiac modulation sensitive to acute emotional stress ( intense anger, fear or sadness ) -- acute emotions, anxiety affects the heart

Hostility and Type A Behavior Pattern

• Type A - easily aroused anger, impatience, hostility, competitive striving, and time urgency and coronary heart disease ( 70’s and 80’s )

• Hostility important predictor of coronary heart disease

Acute mental stress • Staes of ear, excitement, acute anger

reduce blood flow through atherosclerotic coronary segments and provoke coronary spasm, causing abnormal left ventricular wall wall motion

Cardiovascular diseases• Valvular heart disease and anxiety disorder -

association of panic disorder and valvular heart disease

• Coronary artery bypass graft surgery - psychiatric complications especially depression

• Hypertension - personality profiles associated with essential hypertension include persons who have general readiness to be aggressive

Cardiovascular • Vasovagal syncope - acutely stressful events

are known etiological factors • Cardiovascular presentation of psychiatric

disorders - somatization disorder, panic disorder, anxiety and depression can all involve somatic complaints , psychiatric disorder associated with more visits to doctor and impairments in activities of daily living

Respiratory System • Asthma - higher prevalence rates of mood

disorders, post traumatic stress, substance use, and antisocial personality

• Fear of dyspnea may trigger attacks • Personality traits may predispose to more use

of drugs • Intense fear, emotional lability, sensitivity to

rejection, lack of persistence in difficult situations

Respiratory system • Hyperventilation syndrome - often

complain of suffocation, anxiety, giddiness, and light headedness

• Attack aborted by having patient to breath into paper bag

Endocrine System • Hyperthyroidism - mood problems, psychosis • Use of SSRIs , precaution with tricyclics • Hypothyroidism - psychiatric symptoms can

be depressed mood, apathy, impaired memory and other cognitive defects

• Subclinical hypothyroidism - may produce depressive symptoms and cofnitive deficits

Diabetes Mellitus • Psychological factors - onset associated

with emotional stress

• Important are feelings of frustration, loneliness and rejection

• Depressed, they tend to overeat

Adrenal disorders • Hypercortisolism ( Cushing’s

Syndrome ) - excessive secretion of ACTH or from adrenal pathology

Psychiatric symptoms are common because of the effects

Hyperprolactinemia - antipsychotics raise prolactin levels

Skin Disorders • Atopic dermatitis - pruritus and

inflammation ; patients tend to be more anxious and depressed

• Psoriasis - silvery scales with glossy , homogenous erythema

• Leads to stress leading to more psoriasis, leading to interpersonal problems , depression, suicide

Skin disorders • Psychogenic excoriation - lesions caused by

scratching or picking - resembles obsessive compulsion , repetitive

• Localized pruritus - pruritus ani emotional disturbances can precipitate this

• Pruritus vulvae • Hyperhidrosis - anxiety phenomenon ,

emotional stress and other dermatological conditions important

Musculoskeletal system • Rhumatoid arthritis - inflammation of

joints with musculoskeletal pain ; stress may predispose ;m depression comorbid in 20 % of patients ;m poor functioning, pain

• SLE - unpredictable, incapacitating, with toxic drugs , side effects lead to psychosis

Musculoskeletal System • Low back pain - cans tart during

psychological pain, uses psycho education about vasospasm

• Fibromyalgia - pain and stiffness of soft tissues ; relationship of stress, spasm and pain , present in chronic fatigue and depressive disorders ; treatment includes psychotherapy and antidepressants

Headaches • Migraines

• Tension ( muscle or contraction ) headaches

Psycho- oncology • Impact of cancer on psychological

functioning

Treatment of psychosomatic disorders

• Combined treatment • Goals of treatment - mature general life

adjustment , increased capacity for physical and occupational activity , avoidance of complications, reversal of pathology

• Psychiatric aspects - reluctant to deal with emotional problems

• Development of relationship and transference

Medical Aspects • Beahvioral change

• Rapport

• Negotiating strategies by Aaron lazare

• 1. Direct education

• 2. Third party intervention

• 3. Exploration of options

• 4. Provision of sample treatment

Strategies • 5. Control sharing • 6. Concession making • 7. Empathic confrontation • 8. Standard setting

• Relapse - dealing with it entails cognitive, attitudinal, instrumental , coping, social and environmental , contact

Strategies • 5. Control sharing • 6. Concession making • 7. Empathic confrontation • 8. Standard setting

• Relapse - dealing with it entails cognitive, attitudinal, instrumental , coping, social and environmental , contact

Other types of therapy • Group psychotherapy and family

therapy

• Relaxation techniques

• Hypnosis

• Biofeedback

Consultation liaison psychiatry

• Study , practice, and teaching of the relation between medical and psychiatric disorders

• Psychiatrists as consultants • Play many roles • Interviewer, therapist, teacher,

physician as part of the team , diagnosis and treatment

C-L psychiatry • Common C-L problems • Suicide, depression, agitation,

hallucinations, sleep disorder, disorientation, no organic basis for symptoms, non compliance or refusal to consent procedure

• Hemodialysis units ; surgical units, transplantation units

Conclusion • Important to consider psychological

problems of the medically ill patient

• What did you learn today ?

Thank you • For your kind attention and for not

sleeping in my class !