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.

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 pathways.

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 interleukin-1 (IL-1) and IL-6. activation through a variety of pathways including the release of humoral immune factors (cytokines) such as 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 condition.

with the treatment of the general medical (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 exacerbating asthma) affecting medical condition (e.g., anxiety Personality traits disease) 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 Maladaptive health behaviors lack of exercise, overeating) affecting medical condition (e.g., Stress-related physiological response condition (e.g., stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache) affecting general medical Other unspecified psychological factors affecting medical condition (e.g., interpersonal, cultural, or religious 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

several years systems for

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

produces considerable

dysfunction

.

and

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

of

delusional intensity

.

have the certainty

PAIN DISORDER

Preoccupation

with pain is consuming and to some extent

disabling

.

That is, pain becomes the

predominant focus

the clinical presentation and the pain itself causes clinically significant distress or impairment and the patient's life becomes organized around the pain.

of 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 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 medical staff, which result in earlier detection by and more cost-effective problems.

management of patients with psychiatric

MODELS OF COMORBIDITY

MEDICAL ILLNESS

PSYCHIATRIC ILLNESS PSYCHIATRIC ILLNESS

MEDICAL ILLNESS

TREATMENT FOR MEDICAL ILLNESS TREATMENT FOR PSYCHIATRIC ILLNESS

PSYCHIATRIC ILLNESS MEDICAL ILLNESS PSYCHIATRIC ILLNESS MEDICAL ILLNESS

SMOKING AND NICOTINE DEPENDENCE