Transcript Psychological Factors Affecting Medical Condition and

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 hypophysialpituitary 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
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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
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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
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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 !