Transcript Psychosomatic medicine

Psychosomatic medicine
Medically Unexplained Symptoms (MUS)
Bio-psycho-social model
Stress and health
Positive psychology
Psychosomatic medicine
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coronary heart disease
hypertenstion
diabetes
bronchial athma
infertility
morbus Crohn
colitis ulcerosa
cancer
functional aphonia
stuttering
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headaches
fatigue
skin problems
lower back pain
sleep problems
obesity and weight
management
• unhealthy behaviours
related to stress (alcohol,
nicotine, overeating
• eating disorders
Medically unexplained symptoms (MUS)
• Symptoms for which the treating physician,
other healthcare providers, and research
scientists have found no medical cause.
• cause(s) for given symptoms are uncertain,
• A task force of the US National Institutes of
Health states, "Medically unexplained
syndromes (MUS) present the most common
problems in medicine."
Medically unexplained symptoms in primary care
• 14 common physical symptoms are responsible for
almost half of all primary care visits.
• Only about 10–15% of these symptoms are found to
be caused by an organic illness over a 1-yr period.
• An increasing number of medically unexplained
symptoms over a patient's lifetime correlate linearly
with the number of anxiety and depressive disorders
experienced, the score on the personality dimension
of neuroticism, and the degree of functional
impairment.
Katon et al., 1998
What is psychosomatics?
• „Psycho“: mental reaction to our current life
situation
• „Somatic“: how body reacts to our current
situation
Examples ?
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Sayings and Proverbs
• A good laugh and a long sleep are the best cures in the doctor's
book. ~Irish Proverb
• The root of all health is in the brain. The trunk of it is in emotion.
The branches and leaves are the body. The flower of health blooms
when all parts work together. ~Kurdish Saying
• When the head aches, all the body is the worse. ~English Proverb
• To avoid sickness eat less; to prolong life worry less. ~Chu Hui
Weng
Patients with psychosomatic problems:
• 7 years on average; changing doctors, requiring repeated
check-ups
• Before accepting the fact that problems are result of their
own upbrining, reactivity to problems, readiness to solve
problems, personality traits, worcoholism,…;
• Diseases of civilization tend to be more frequent
• Psychotherapy and psychosomatic medicine is not taught at
the academic medicine at all; bio-psycho-social model is not
taught
• As a result people search for healers
Medicine in 21st century:
„Tools“ and/or „Talking?“
Tools and equipment medicine;
„academic medicine“
Talking medicine
Bio-psycho-social model
Biomedical model
Psychosocial model
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Bio-psycho-social model
• a conceptual model that assumes that
psychological and social factors must also be
included along with the biologic in
understanding a person's medical illness or
disorder.
Bio-psycho-social model:
Integrated approach to human behaviour, disease and
healthcare
Genes
Drugs
Germs
Biological factors
Personality traits
Motivation
Optimism
Psychological factors
Occupational stress
Stigma
Family environment
Life Events
Social factors
Engel, 1977
Bio-psycho-social model
• The biological system: deals with anatomical,
structural and molecular substrate of disease and the
effects on the paitent´s biological functioning
• Psychological system: deals with effects of
psychodynamic factors like motivation, personality,
optimism, on the experience of and reaction to
illness
• Social system: examines the cultural, environmental
and familial influences on the expression and
experience of the illness
Study of the relationship between sudden
deaths and psychological factors: Background
• 170 sudden deaths over 6 years
• Serious illness or even death might be
associated with psychological stress or
trauma.
Engel, 1971
Study of the relationship between sudden
deaths and psychological factors: Triggers
• the impact of the collapse or death of a close
person;
• during acute grief;
• on threat of loss of a close person;
• during mourning or on an anniversary;
• on loss of status or self-esteem;
• personal danger or threat of injury;
• after the danger is over;
• reunion, triumph, or happy ending.
Engel, 1971
Study of the relationship between sudden
deaths and psychological factors. Conclusion
• Common to all is that they involve events impossible for
the victims to ignore and to which their response is
overwhelming excitation or giving up, or both.
• this combination provokes neurovegetative responses,
involving both the flight-fight and conservationwithdrawal systems, conducive to lethal cardiac events,
particularly in individuals with preexisting cardiovascular
disease; other modes of death, however, were also noted.
• Better understanding of the potentially lethal life situations
and identification of individuals at risk may lead to the
development of practical prophylactic measures.
Suggest practical
prophylactic measures (???)
Engel, 1971
Effects of Bereavement on Physical and mental health
– a study of the medical records of widows
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The medical records kept before and after the bereavement of 44 unselected London
widows
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In widows under the age of 65 the consultation rate for psychiatric symptoms more than
trebled during the first six months after bereavement. The increase was greatest during the
first six months.
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The amount of sedation prescribed to widows under the age of 65 was seven times greater
during the 18 months after bereavement than it had been during the control period, not
for widows over the age of 65.
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The consultation rate for non-psychiatric symptoms increased by nearly a half in both older
and younger widows. This change in the consultation rate was most pronounced in the
subgroup diagnosed " osteoarthritis," which increased by one and a half times after
bereavement.
Parkes, 1964
Effects of Bereavement on Physical and mental health
– a study of the medical records of widows:
Conclusion
„Grief
is a syndrome which commonly causes the
widow to seek help from her general
practitioner.
As yet little attention has been paid to it in the
medical curriculum.“
Parkes, 1964
Life events
and
life stress,
1967
The Social
readjustment
Rating Scale
Scoring the Life Change Index
„The body is a finely instrument
that does not like surprises.
Any sudden change stimuli which affects
The body, or the rreordening of important
Routines that tho body become used to,
Can couse needless stress, throuwing
Your whole physical being into turmoil.
Life Change Units and likelihood of illness
in near future:
300+: about 80%
150-299: about 50%
Less than 150: about 30%
Occupational Stressors
San Fransico Bus Drivers, Heart Attacks and
hypertension
Occupational stressors: Bus driving and hypertension
41.5% of the transit workers had
hypertension
compared to 27.6% for all the 214,413
workers studied.
Study of the natural history of hypertension. Biological and psychological factors
Stage of Disease
Physiology
Affective
Cognitive
Normotensive/youth
(genetic/familial risk)
All normal possible hyperreactivity to lab stress,
Anger? Reduced pain
Mild elevation in SBP
sensitivity
Opioid dysregulation
Borderline/Prehypertensive
BP >119/79 <140/90 with
predominance of
elevated DBP,
sympathetic activation
High cardiac output
Baroreceptor adjustment;
hyper reactivity to lab
stress
Interpersonal difficulty
Pain insensitivity Less
awareness negative
affect, positive affect?
Early Hypertension
(40–60yrs)
BP >140/90 High TPR
Salt/diet sensitive
Renin/angiotensin
Aldosterone Sympathetic
Structural/function brain
changes Hyperreactivity
Above with transition to
greater negative affect
with inhibition of the
expression of intense
angry cognitive and
emotive reactions
Mild deficits executive
attention, working
memory
Late Hypertension
(60+ yrs)
Same BP or isolated
systolic hypertension?
maintenance of altered
regulatory system
Continued high negative
affect and expression of
negative affect?;
awareness of BP status
may invert relationship
Deficits not as clear
relative to age matched;
Related to Alzheimer's
Disease
Subtle spatial attention,
short term memory
deficit
Jennings and Heim, 2011
Biological, psychological and social factors influence:
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the prevention,
causes,
Presentation,
management
and outcome of the diseases
Bio-psycho-social model and schizophrenia management
Stress
Neurocognitive
Impairment +
Dopamine dysregulation
Early warning signs
Relapse
De-stigmatization
Family psychoeducation
Social Skills training
Assisted working
Antipsychotic medication
Cognitive rehabilitation
Psychoeducation
ITAREPS
Family Environment and Schizophrenia outcome
„Patients have families“
Henry
• Schizophrenogenic mother
(Fromm-Reichmann, 1949)
• Family influence is an
etiology factor, not a
method for recovery (Palo
Alto Mental Research Institute,
1950)
• Double bind theory:
deviance in communication
= schizophrenogenic
communication (Bateson,
1956)
Richardson,
1948
Pilgrim State Hospital,
USA, 1954:
13 875 patients
Pharmacological
revolution in psychiatry:
Deinstitutionalization!
Family Environment and Schizophrenia
outcome
• Interpersonal atmosphere in a household
influences the course of the illness
(Brown, 1966)
• High Expressed Emotions, (HEE) as a trigger
of relapse: hostility, emotional overinvolvement and critical comments
(Vaughn a Leff, 1976)
Patients at home,
relatives need
information
Family psychoeducation and relapse prevention
Relatives:
↓anxiety, expectations, self-blaming
↑communication skills
Environment:
↓stress
↓relapse risk
Patients:
↓ anxiety, hopelessness
↑ treatment adherence
Stress and health
Psychology
• Anxiety
• Anger, rage
• Apathy, depression
• Cognitive dysfunction
Fight of
flight
Physiology
• ↑ metabolism
• ↑ heart rate
• ↑ blood pressure
• ↑ breathing
• ↑ muscle tone
• ↑ endorphins and ACTH
Hans Selye, 1907-1982
Canadian physician and medical teacher,
born in Austria
General Adaptation Syndrome.
“The absence of stress is death.
Only the dead has no stress.“
Posttraumatic Stress Disorder
Burn-out syndrome
• result of long-term occupational stress
• long-term exhaustion and diminished interest
in work
• about 90% of burned out workers meet
diagnostic criteria for depression, suggesting
that burnout may be a depressive syndrome
rather than a new or distinct entity
Interventions
Relaxation techniques
Positive psychology
How does it work?
Positive psychological
attributes promote health
Hope
Self-efficacy
Optimism
Resiliency
Biological correlates of happiness over the working day.
a: mean salivary cortisol averaged during the working day in relation to hapiness
b: Mean heart rate averaged during the working day in relation to happiness in men
(black bars) and women (hatched bars).
Steptoe et al., 2005
Positive psychology interventions and
cardiac health
• Positive psychological attributes--especially optimism--may
be independently associated with superior cardiac
outcomes.
• Positive attributes appear to be associated with increased
participation in cardiac health behaviors (e.g., healthy
eating, physical activity) linked to beneficial outcomes;
• Data linking positive psychological states and biomarkers of
cardiac health (e.g., inflammatory markers) is mixed but
suggests a potential association.
• Positive psychological interventions have consistently been
associated with improved well-being and reduced
depressive symptoms, though there have been few such
studies in the medically ill.
Dubois et al., 2012
Positive
psychology
interventions
Integrating positive psychology in practice
• Three good things. Every evening, write down three good things
that happened that day and think about why they happened.
• Gratitude visit. Write a letter to someone explaining why you feel
grateful for something they’ve done or said. Read the letter to the
recipient, either in person or over the phone.
• Reverse the focus from negative to positive. Shift attention to
more positive aspects of life.
1) take a mental spotlight each night and scan over the events of the
day, thinking about what went right.
2) compile “I did it” lists instead of only writing down what needs to be
done.
Integrating positive psychology in practice
Develop a language of strength.
• Talk or identify more positive qualities and personal
strengths.
• Just as an athlete exercises certain muscles to become
stronger, the theory is that people who use their strengths
regularly will function better in life: identify one top
strength and then use it at least once a day.
Build strategies that foster hope.
• reduce the scope of the problem by breaking it down into
components that can be tackled one at a time.
5 mm rule
„Turn that
frown upside
down“