Transcript 13-PSYCHOSOMATIC MEDICINE

PSYCHOSOMATIC
MEDICINE
Dr. YASER ALHUTHAIL
Associate Professor & Consultant
Consultation Liaison Psychiatry
Psychosomatic medicine is an area of scientific
investigation concerned with the relation between
psychological factors and physiological phenomena in
general and disease pathogenesis in particular.
Unity of mind and body
Integrates mind and body into a psychobiological unit; as
dynamic interacting systems.
A holistic approach to medicine.
Implications:
Unity of mind and body:
Psychological factors must be taken into account when
considering all disease states
Emphasis on examining and treating the whole patient,
not just his or her disease or disorder.
The concepts of psychosomatic medicine also influenced
the field of behavioral medicine which integrates the
behavioral sciences and the biomedical approach to the
prevention, diagnosis, and treatment of diseases.
Psychosomatic concepts have contributed greatly to those
approaches of medical care.
Biomedical Model:
The application of biological science to maintain health
and treating disease.
Engel (1977) proposed a major change in our fundamental
model of health care.
The new model continues the emphasis on biological
knowledge, but also encompasses the utilization of
psychosocial knowledge.
“Biopsychosocial Model”
STRESS THEORY
Stress can be described as a circumstance that disturbs,
or is likely to disturb, the normal physiological or
psychological functioning of a person.
The body reacts to stress in this sense defined as
anything (real, symbolic, or imagined) that by 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.
THE STRESS MODEL
A psychosomatic framework.
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
mediate the second facet.
NEUROTRANSMITTER
RESPONSES TO STRESS
Stressors activate noradrenergic systems in
the brain and cause release of catecholamines
from the autonomic nervous system.
Stressors also activate serotonergic systems
in the brain, as evidenced by increased
serotonin turnover.
Stress also increases dopaminergic
neurotransmission in mesoprefrontal
ENDOCRINE RESPONSES TO
STRESS
CRF is secreted from the hypothalamus.
CRF acts at the anterior pituitary to trigger release of
ACTH.
ACTH acts at the adrenal cortex to stimulate the
synthesis and release of glucocorticoids.
Promote energy use, increase cardiovascular activity,
and inhibit functions such as growth, reproduction,
and immunity.
IMMUNE RESPONSE TO
STRESS
Inhibition of immune functioning by glucocorticoids.
Stress can also cause immune activation through a
variety of pathways including the release of
humoral immune factors (cytokines) such as
interleukin-1 (IL-1) and IL-6.
These cytokines can themselves cause further release
of CRF, which in theory serves to 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.
Changes in the immune system in response to
stress are now very well established.
Immune suppression in response to stress occurs
even after removal of the adrenal gland !!.
There appears to be an alternative path, other
than through the adrenals, for the brain to
influence the immune response.
Psychoneuroimmunology
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., 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, 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)
The essential challenge in psychosomaticpsychobiological research is to delineate the
mechanisms by which experiences cause
certain types of physiological reactions that
result in disease states.
HYPERTENSION
Psychological factors have been closely studied as part
of the pathogenesis of the condition.
Relatively strong evidence indicates that some persons
have greater blood pressure reactivity than do others .
Various behavioral procedures including biofeedback,
relaxation training, and psychotherapy have been used
as interventions.
GASTROINTESTINAL CONDITIONS
Recent studies have shown that personality
features of hostility, irritability, hypersensitivity, and
impaired coping ability correlate significantly with
serum pepsinogen concentration in peptic ulcer
disease patients.
Irritable Bowel Syndrome is the most frequently
documented gastroenterological syndrome that has
been related to psychiatric influences.
There is a strong & consistent association between
functional gastrointestinal disorders and
psychological factors.
SOMATOFORM DISORDERS
Three enduring clinical features:
- Somatic complaints that suggest major
medical problems.
- Psychological factors and conflicts that seem
important.
- Symptoms or magnified health concerns that
are NOT under the patient’s conscious
control.
SOMATOFORM DISORDERS
Somatization disorder
Conversion disorder
Pain disorder
Hypochondriasis
Body Dysmorphic Disorder
SOMATIZATION DISORDER
The essential feature of somatization disorder is
recurrent, multiple somatic complaints requiring
medical attention but not associated with any
physical disorder.
Somatization disorder is the expression of
personal and social distress in bodily complaints .
Multiple symptoms of multiple systems for
several years
Chronic relapsing condition with no known cure.
CONVERSION DISORDER
A disturbance of body functioning (usually
neurological) that does not conform to current
concepts of the anatomy and physiology of the
central or the peripheral nervous system.
It typically occurs in a setting of stress and
produces considerable dysfunction.
Involuntary movements, tics, seizures, abnormal
gait, paralysis, weakness etc.
HYPOCHONDRIASIS
Preoccupation with the fear of developing a
serious disease or the belief that one has a serious
disease.
The fear is based on the patient's interpretation
of physical signs or sensations as evidence of
disease even though the physician's physical
examination does not support the diagnosis of any
physical disorder.
However, the belief does not have the certainty
of delusional intensity.
PAIN DISORDER
Preoccupation with pain is consuming and to
some extent disabling.
That is, pain becomes the predominant focus of
the clinical presentation and the pain itself
causes clinically significant distress or
impairment and the patient's life becomes
organized around the pain.
Psychological factors are judged to play a role
in this disorder.
BODY DYSMORPHIC DISORDER
Preoccupation with an imagined defect in
appearance. If a slight physical anomaly is
present, the person's concern is markedly
excessive.
The preoccupation causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
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
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
nonpsychiatrist physicians for teaching
psychosocial aspects of medical care.
CONSULTATION LIAISON
PSYCHIATRY
CL psychiatrist MUST have an extensive
clinical understanding of physical/neurological
disorders and their relation to abnormal illness
behavior.
CL psychiatrist MUST have knowledge of
psychotherapeutic and psychopharmacological
interventions
CONSULTATION VS. CONSULTATION-LIAISON
Liaison psychiatrist may participate in ward rounds and
team meetings while addressing the behavioral issues.
Education of nonpsychiatric physicians and health
professionals about medical and psychiatric issues
related to a patient’s illness.
Liaison services lead to heightened sensitivity by
medical staff, which result in earlier detection and more
cost-effective management of patients with psychiatric
problems.
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