Transcript PSYCHOSOMATIC Class

PSYCHOSOMATIC
(MIND-BODY)
MEDICINE
Hamid Afshar MD.
Associate Professor of Psychiatry
Psychosomatic Research Center
[email protected]
‫پزشکی روان تني (سايكوسوماتيك)‬
‫بين ذهن و بدن انسان ارتباط و تعامل پيچيده و‬
‫پويايی وجود دارد“‬
‫قرن هاست انسان متوجه اين تعامل و ارتباط دو سويه شده است‪ .‬در واقع تاثيرات دو طرفه ای‬
‫که از طرف جسم بر وضعيت روانی و از طرف روان بر عملکرد جسمی اعمال می شود فقط‬
‫برای پزشکان آشکار نيست بلکه افراد غير متخصص نيز که از دقت کافی برخوردار باشند‬
‫تصديق می کنند که در زمان های افزايش استرس و تنش های روانی ‪ ،‬فعاليت و عملکرد‬
‫جسمی و سالمت بدنی ‪ ،‬تحت تاثير قرار می گيرد و يا بهبود بيماری ها به تاخير می افتد‪.‬‬
‫پزشکی روان تني بر تعامل و تأثير متقابل فرايندهاي جسمی‪ ،‬روانی و‬
‫اجتماعي در شکل گيری‪ ،‬تشديد ‪ ،‬سير درمان و پيامد بيماريها تاکيد دارد‪.‬‬
‫در پزشکی روان تنی چگونگی تاثير فعاليت های ذهنی بر سالمت و چگونگی‬
‫به کار گيری تدبيرها در جهت کاهش استرس از طريق تغيير شناختی و يا‬
‫هيجانی در راستای سالمت است‪.‬‬
A holistic approach to medicine
Relation between psychological factors
and physiological phenomena in general
and disease pathogenesis and illnesses in
particular.
Unity of mind and body
Dynamic interacting systems
‫تغيير الگوی بيماريها در قرن اخير نشان دهنده کاهش‬
‫مرگ ومير بيماری های عفونی و مسری و افزايش‬
‫بيماری های مزمن و غيرواگير است‪.‬‬
‫به همين علت در چند دهه اخير‪ ،‬بيماری های مزمن و اختالالت روان تنی نيز بيشتر مورد‬
‫توجه قرار گرفتند‪ .‬ويژگی اساسی اين تغيير‪ ،‬پر رنگ شدن نقش عوامل روانی اجتماعی و‬
‫فرهنگی و اهميت يافتن تاثير ساختارها و رفتارهای اجتماعی بر پيدايش‪ ،‬سير و توزيع و‬
‫درمان بيماری و ناخوشی انسانها است‪.‬‬
‫استرس و سبک زندگی به عنوان يک عامل مهم و موثر به همراه‬
‫عوامل ديگر در تمامی اختالالت روان تنی ديده میشود‪.‬‬
THE STRESS MODEL
Stress disturbs or is likely to disturb normal
physiological or psychological function.
The body reacts to stresses (real, symbolic, or
imagined); threatens an individual's survival by
putting into motion a set of responses that seeks to
diminish the impact of the stressor and restore
homeostasis.
Endocrine Responses to Stress
Two major facets of stress response:
“Fight or Flight” response is mediated by hypothalamus, the
sympathetic nervous system, and the adrenal medulla.
If chronic, this response can have serious health consequences.
The hypothalamus, pituitary gland, the adrenal cortex (HPA)
mediate the second facet. CRF/ ACTH
Immune Response to Stress
Immune activation release of (cytokines)
interleukin-1 (IL-1) and IL-6.
These cytokines release of CRF increase
glucocorticoid effects and thereby self-limit the
immune activation.
High level of Cortisol results in suppression of
immunity which can cause susceptibility to
infections and possibly also in many types of
cancer.
Psycho-Neuro-Immunology
Psycho-NeuroImmunology (PNI)
The link between the Nervous System,
the Immune System and Behavior
The Nervous
System
(Neurobiology)
Behavior
(Psychology)
Weintraub, 2007
PNI
The Immune
System
(Immunology)
‫چه بيماريهائي روان تنی (سايكوسوماتيك)‬
‫هستند؟‬
‫در چه بيماريهايی عوامل روانی وذهنی نقش ندارند؟‬
‫الف) برخي از بيماريهاي جسمی به دليل عوامل رواني مثل‬
‫استرس يا اضطراب ايجاد يا تشديد مي شوند‪.‬‬
‫براي مثال اِگزما‪ ،‬زخم معده‪ ،‬پسوريازيس‪ ،‬فشار خون وبرخی‬
‫بيماريهاي قلبي يا روماتيسمی با وضعيت رواني ارتباط تنگاتنگی‬
‫دارند ‪ .‬اگرچه بسياري از بيماران مدعي هستند وضعيت روحي –‬
‫رواني آنها به دليل بيماري جسمي آنها است‪ .‬ولی در حقيقت اين‬
‫رابطه و تعامل دو سويه است‪.‬‬
‫ب) استرس مي تواند سيستم ايمني بدن را در ابتدا تحريك و‬
‫پس از آن مهار كند‪.‬‬
‫مرگ نزديكان‪ ،‬جدائي و طالق كه منجر به تنهائي مي شوند‬
‫اضطراب‪ ،‬افسردگي‪ ،‬استرس ها روي سيستم ايمني اثر‬
‫مي گذارد‪ .‬در شکل گيری بيماريهای وخيم مثل سرطان ها‪،‬‬
‫استرس و ناخوشی های روانی مورد توجه جدی قرار‬
‫گرفتند و پژوهش های زيادی در اين مورد در حال‬
‫پيشرفت است‪.‬‬
‫پ) اختالالت عملکردی دستگاه های مختلف بدن از جمله‬
‫سندرم روده حساس‪ ،‬سوءهاضمه غيرزخمي‪ ،‬تهوع‬
‫مزمن ‪ ،‬كمردرد‪ ،‬فيبروميالژي‪ ،‬دردهای غيرقلبي قفسه‬
‫سينه ‪ ،‬نفس تنگی وحمالت تنفس سريع مرتبط با استرس‬
‫يا اضطراب‪ ،‬سندرم خستگي مزمن‪ ،‬سردردهاي عصبي‪،‬‬
‫ميگرن وسردردهای تنشی ‪ ،‬دردهاي غيراختصاصي‬
‫صورت‪ ،‬سختي بلع (گلوبوس)‪.‬‬
Functional somatic syndromes by specialty
Cardiovascular System
Psychological factors have been closely studied as part
of the pathogenesis of the cardiovascular diseases.
Depression is an independent risk factor for the
development of coronary artery disease.
Depression increases mortality rates following
myocardial infarction (MI).
Hyperactivity of (HPA) , immune activation with release of proinflammatory
cytokines, and activation of the sympathetic nervous system and of
corticotropin-releasing factor (CRF) pathways in the central nervous system
(CNS).
Gastrointestinal System
Functional disorders represent 50% of
complaints in GI clinics
There is a strong & consistent association
between functional gastrointestinal disorders and
psychological factors
Irritable Bowel Syndrome
Brain-Gut axis
Hypersensitivity of GI tract
Role of stress
‫فشار ها و استرس های رواني مي توانند عالئم جسمي‬
‫بوجود آورند در حاليكه يك بيماري خاص را نمي توان‬
‫تشخيص داد‪.‬‬
‫مثالً افراد گاهي به دليل استرس درد قفسه سينه پيدا مي كنند‬
‫ولي هيچ بيماري قلبي در آنها يافت نمي شود‪ .‬يا ترس و‬
‫وحشت فرد را دچار استفراغ و دل درد می کند بدون اينکه‬
‫يک بيماری گوارشی واضح کشف شود‪.‬‬
Somatic symptom disorder

A. One or more somatic symptoms that are distressing and/or result in
significant disruption of daily life.
B. Excessive thoughts, feelings, and behaviors related to these somatic
symptoms or associated health concerns: At least two of the following are
required to meet this criterion:
(1) Disproportionate and persistent concerns about the medical seriousness
of one’s symptoms.
(2) High level of health-related anxiety
(3) Excessive time and energy devoted to these symptoms or health concerns


C. Chronicity: Although any one symptom may not be continuously
present, the state of being symptomatic is chronic (at least 6 months).



Predominant Pain* (previously pain disorder):
predominantly with pain complaints.
individuals presenting
Persistent: A Persistent course is characterized by severe symptoms,
marked impairments, and long duration(>6mo).
Severity: Mild (only one symptom with criterion B …) – Moderate (two or
more with criterion B) –Severe(two or more in Critrion B plus multiple
somatic complaints )
*Patients with other presentations of pain may better fit ;
adjustment disorder
psychological factors affecting a medical condition
depressive disorders
Functional Neurological Disorder
( Conversion disorder )

Neurological symptoms / regardless appropriate medical assessment/
incompatible with a neurological condition:
weakness or paralysis, events resembling epilepsy or syncope, abnormal movements,
sensory symptoms (including loss of vision and hearing), or speech and swallowing
difficulties.



The symptoms may be acute or chronic.
Psychological stressors or personally meaningful life events may often be
associated with onset of symptoms, but their identification is not necessary for
the diagnosis.
Co-morbid neurological disease may also be present and does not exclude
the diagnosis.
Criteria A, B, C and D must all be fulfilled to make the FND
diagnosis:




A. One or more neurologic symptoms such as altered voluntary
motor, sensory function, or seizure-like episodes
B. The symptom, after appropriate medical assessment, is not
found to be due to a general medical condition, the direct effects
of a substance, or a culturally sanctioned behavior.
C. The physical signs or diagnostic findings are internally
inconsistent or incongruent with recognized neurological disorder.
D. The symptom causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning or
warrants medical evaluation.
Illness worries
Illness worries are thoughts about illness or symptoms that make patient
worry that he/she may be seriously ill.
Illness anxiety disorder




A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in
intensity. If a general medical condition or high risk for developing
a general medical condition is present, the preoccupation is clearly
excessive or disproportionate.
C. There is a high level of anxiety about health or having or
acquiring a serious illness and the individuals is easily alarmed
about personal health state.
D. Excessive behaviors (e.g. checking one's body for signs of
disease, repeatedly seeking information and reassurance from
the internet or other sources), or exhibits maladaptive avoidance
(e.g. avoiding doctor's appointments and hospitals, avoiding
visiting sick friends or relatives, avoiding triggers of illness fears
such as exercise).


E. Illness preoccupation has been present for at least 6 mo, but the
specific illness that is feared may change over the time period.
F. Not better accounted for by another mental disorder such as
somatic symptom disorder, panic disorder, generalized anxiety
disorder, or obsessive compulsive disorder or delusional disorder
( somatic type).
Specify whether:
Care seeking type
Care avoidant type
‫بعضی اختالالت جسمی که جنبه های روانی و روان‬
‫تنی در آن قابل توجه است‪:‬‬
‫کوليت اولسرو‪ ،‬آسم‪ ،‬جوش و آکنه‪ ،‬واکنش های‬
‫آلرژی‪ ،‬کهير‪ ،‬کاهش قند خون‪ ،‬افزايش ترشح غدد‬
‫داخلی‪ ،‬ديابت نوع دو‪ ،‬چاقی‪ ،‬فشار خون اساسی‪،‬‬
‫بيماری کرونر قلب و بی نظمی ضربان قلب‪.‬‬
DSM-IV Diagnostic Criteria for Psychological
Factors Affecting Medical Condition
A. A general medical condition (coded on Axis III) 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 a close temporal association between the psychological factors and
the development or exacerbation of, or delayed recovery from, the general
medical condition.
(2) the 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 a
general medical condition.
Mental disorder affecting medical condition (e.g., an Axis I
disorder such as major depressive disorder delaying
recovery from a myocardial infarction)
Psychological symptoms affecting medical condition (e.g.,
depressive symptoms delaying recovery from surgery;
anxiety exacerbating asthma)
Personality traits or coping style affecting medical
condition (e.g., pathological denial of the need for surgery
in a patient with cancer, hostile, pressured behavior
contributing to cardiovascular disease)
Maladaptive health behaviors affecting medical
condition (e.g., lack of exercise, unsafe sex,
overeating)
Stress-related physiological response affecting
general medical condition (e.g., stress-related
exacerbations of ulcer, hypertension, arrhythmia,
or tension headache)
Other unspecified psychological factors affecting
medical condition (e.g., interpersonal, cultural, or
religious factors)
Consultation Liaison Psychiatry
The subspecialty of psychiatry that incorporates
clinical service, teaching, and research at the
borderland of psychiatry and medicine.
Liaison refers to interactions with
non psychiatrist physicians for teaching
psychosocial aspects of medical care.
knowledge of psychotherapeutic and
psychopharmacological interventions
MODELS OF COMORBIDITY
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
TREATMENT FOR
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
TREATMENT FOR
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
SMOKING AND NICOTINE
DEPENDENCE
Medical illnesses
stress
CLP
Mind – Body
interaction
Psychological state
Psychiatric disorders
Somatoforms (somatic symptoms disorders)
Health
Functional
disorders
MANAGEMENT
Caring rather than curing
Management is more realistic than treatment
Therapeutic relationship
Nature of symptoms in psychosomatic context
Rule out depression and anxiety disorders
Avoid investigations without indications
Pharmacotherapy
Coping skills
Lifestyle changes