Transcript Slides Dr. Ridwan 7

It starts with the story:
Listening to patients
Radwan Banimustafa MD
The university of Jordan medical school
"The good
physician will treat
the disease, but the
great physician will
treat the patient."
Sir William Osler, M.D.
What are the connections?
?
Brain
?
Mind
?
Body
Early understandings
The soul is in the very likeness of the divine, the
immortal, the intellectual…. The body is an
enclosure or prison in which the soul is
incarcerated. – Plato (Cratylus)
The seat of the soul and the control of voluntary
movement - in fact, of nervous functions in
general, - are to be sought in the heart. The
brain is an organ of minor importance.
Aristotle (De motu animalium, 4th century B.C.)
It seems to me an acceptable assertion that
the soul itself resides within the brain
where the activity of thought is produced,
and the memory of sensorial images is
stored there.
Galen (129-199 A.D.)
For the next 1600 years…..
Respect for the body as “created in the
image of God” precludes systematic
scientific investigation
 Gradually the church permits the body
to be studied by the scientists
 The soul is left to the theologians and
philosophers

The soul and body are separate…
“If the filaments that compose
the marrow of these nerves
are pulled with force enough
to be broken and thus are
separated from the part to
which they were joined, so
that the structure of the whole
machine is less intact, the
movement they cause in the
brain will cause the soul to
experience a feeling of pain.
Treatise of Man
…but the soul is present in the brain.
"Pain in the hand is
felt by the soul not
because the soul
is present in the
hand but because
the soul is
present in the
brain."
Principles of Philosophy
The mind (soul) and body connection

Pineal gland was the interface, connecting the
animal spirits and the bodily sensations
 Cartesian dualism has had a profound effect on
medicine:
– emphasis on biology
– reductionism
– tissue damage, disease and symptoms are
proportional
The mind – brain connection
After the accident, “… the equilibrium or balance,
so to speak, between his intellectual faculties
and animal propensities, seems to have been
destroyed. He is ... irreverent, indulging at
times in the grossest profanity (which was not
previously his custom), manifesting but little
deference for his fellows, impatient of restraint
or advice when it conflicts with his desires ...
obstinate, yet capricious and vacillating,
devising many plans of future operation, which
are no sooner arranged than they are
abandoned in turn for others.…”
Harlow, John M. Recovery from the Passage of an Iron Bar Through the Head,
1868, Publication of the Massachusetts Medical Society, 2:327
The mind and the mind-body connection:
Sigmund Freud

Obtained MD in 1881, worked as a neurologist
 Couldn’t explain common and important clinical
phenomena using neurological models alone
 Hypothesized an inner world: the mind
 The mind had a structure similar to the brain, and “rules” of
operation
 Discovered the “talking cure”: discussion of the onset of
certain symptoms (phobias, paralyses, pains) frequently
led to their abatement
 Example: a soldier who became blind in battle regains his
sight when he talks of “no longer wishing to see the
trauma of combat”.
Freud’s model of the mind
structure
topography
SUPEREGO
(conscience)
PRECONSCIOUS
(memory)
EGO
(awareness)
CONSCIOUS
(awareness)
ID
(impulses)
repression barrier
UNCONSCIOUS
(the closet)
The brain-body connection:
Hans Selye

Stress: the inability to cope with a physical or
emotional threat
 3 stages:
• Alarm: fight or flight response (nervous and endocrine
systems activated for defense against stressor)
• Resistance: continued high alert (hormones helpful in
alarm stage now become counterproductive increasing
risk for disease)
• Exhaustion: body no longer able to cope

Showed that the brain could, literally, kill the body
Nerves
Hormones
Action
Brain
Endocrine glands
Physiology
and Behavior
environment
Immune system
That was then…
Gage and head injury
Brain
Mind
Selye and stress
Freud and
mysterious symptoms
Body
… this is now
The biological basis of
Psychiatric disorders
Brain
Mind
Biopsychosocial
model
PsychoneuroImmunology
Medically unexplained
physical symptoms
Body
So, what does it mean to be a patient?
Becoming a patient
“Patients are human beings with very human
hopes and fears. In the hospital, they have
been removed from their accustomed
environment. Their valuables and their clothes
have been taken away from them, and they
feel “miserable, scared, defenseless, and, in
their nakedness, unable to run away”.
Francis W. Peabody, MD
in a 1927 lecture to Harvard Medical Students.
Signs and symptoms





Signs: ‘objective’ manifestations of a disease
process (e.g., a rash, high blood pressure)
Symptoms: ‘subjective’ experiences (pain or other
form of distress)
Healthy individuals develop a new physical
symptom every 5 - 7 days
95% of these symptoms are never brought to the
attention of a doctor.
Question: What are symptom characteristics that
might make you go to the doctor?
Why symptoms lead to medical visits








Intensity
Duration
Change in presentation
Family history
Previous experience
Unfamiliarity
Perceived threat
Loss of control
Disease and Illness
Disease: an objective pathological
process or injury
 Illness: a subjective sense of one’s
state of health
 Usually these happen together. But not
always…….

Your first night on call
You are the medical student in the ER
tonight.
 Two patients have been admitted with
chest discomfort
 Your job is to interview them and find
out what’s going on

Mr. K
Patient: 53 year old man with no history of
heart disease. Came to the ER reluctantly
at the insistence of his wife because of
chest discomfort
 Findings: abnormal EKG, cardiac enzymes
 Diagnosis: Myocardial Infarct
 Expectation: Patient wants to leave ER now
to go back to work, states discomfort is “not
that bad”. Asks that you discharge him
immediately.

Mr. S

Patient: 48 year old man with no history of heart
disease. Ninth ER visit this month for complaints of
chest pain, no previous findings. Patient has had
multiple thorough workups including cardiac
catheterization as well as pulmonary and
gastroenterology consults (all normal).
 Findings: normal exam, EKG, cardiac enzymes
 Diagnosis: not clear
 Expectation: Patient wants to be admitted again.
Says the pain is “worse than ever”. Feels he cannot
go home. He’s pulling on your sleeve.
How do people become patients?




A symptom is recognized and its associated
functional impairment is experienced
The symptom is interpreted and attributed to
some health problem (i.e., the symptom has
meaning)
The person becomes a patient and uses health
care (forms a relationship with a health care
professional)
He or she may remain a patient until the
symptom remits.
Patients vary greatly in their
reactions to common symptoms
Genetic or constitutional
predisposition
Personal experience, learned
patterns of attribution and
response
System of medical care, health
benefits, financial incentives,
family and peers, environmental
stressors and resources
Biological
factors
Psychological
factors
Social factors
How can we keep track of all
this information?
Case #1

Mary is a 45 year old woman with diabetes
who presents with a 1-month history of
“not feeling herself.” She states that she
has difficulty sleeping, poor appetite, poor
concentration and constant fatigue.
Case #1
Mary is a 45 year old woman with diabetes
who presents with a 1-month history of
“not feeling herself.” She states that she
has difficulty sleeping, poor appetite, poor
concentration and constant fatigue.
 What would you do about these
symptoms?

Biopsychosocial formulation
Biological
(brain-body)
What we
see
Sleep,
appetite,
concentration
fatigue
What might Diabetes or
be the
Major
cause
Depression (a
neuro-chemical
imbalance)
What we
might do
?
Biopsychosocial formulation
Biological
(brain-body)
What we
see
Sleep,
appetite,
concentration
fatigue
What might Diabetes or
be the
Major
cause
Depression (a
neurochemical
imbalance)
What we
might do
Medication
Progress of treatment
100
90
80
70
60
50
40
30
20
10
0
Prior level of function: busy
mother of 3, preschool teacher
Medications:
Insulin adjusted
Prozac started
Blood sugar
now normal
1
2
3
5
6
7
8
Case #1
Mary is a 45 year old woman who
presents with a 1-month history of “not
feeling herself.” She states that she has
difficulty sleeping, poor appetite, poor
concentration and constant fatigue. She
rarely goes out anymore with her friends
and spends most of her time with her
alcoholic husband who is physically
abusive.
 What do these new data tell us?

Biopsychosocial formulation
What we
see
What
might be
the cause
What we
might do
Biological
Social
(brain-body)
(environment)
Sleep,
appetite,
concentration,
fatigue
Diabetes or
Major
Depression (a
neurochemical
imbalance)
Medication
Isolation,
abuse
Domestic
violence
relationship
?
Biopsychosocial formulation
Biological
Social
(brain-body)
(environment)
What we
see
Sleep,
Isolation,
appetite,
abuse
concentration,
fatigue
What
might be
the cause
Diabetes or
Domestic
Major
violence
Depression (a relationship
neurochemical
imbalance)
What we
might do
Medication
Women’s
Shelter, social
support
Progress of treatment
100
90
80
70
60
50
40
30
20
10
0
Goes to women’s shelter
What happened here?
1
2
3
5
6
7
8
Case #1

Mary is a 45 year old woman who presents with a
1-month history of “not feeling herself.” She states
that she has difficulty sleeping, poor appetite, poor
concentration and constant fatigue. She rarely
goes out anymore with her friends and spends
most of her time with her alcoholic husband who is
physically abusive. She has little interest in fun
activities, has a negative view of almost everything,
and feels that she is a failure as a mother.
 What do these new data tell us?
Biopsychosocial formulation
Biological
Psychological
Social
(brain-body)
(mind)
(environment)
What we
see
Sleep,
Boredom, poor
appetite,
self-image,
concentration, negativity
fatigue
What
might be
the cause
Diabetes or
Childhood abuse Domestic
Acute Major
and neglect
violence
Depression (a
relationship
neurochemical
imbalance)
What we
might do
Medication
?
Isolation,
abuse
Women’s
Shelter, social
support
Biopsychosocial formulation
Biological
Psychological
Social
(brain-body)
(mind)
(environment)
What we
see
Sleep,
Boredom, poor
appetite,
self-image,
concentration, negativity
fatigue
What
might be
the cause
Diabetes or
Childhood abuse Domestic
Acute Major
and neglect
violence
Depression (a
relationship
neurochemical
imbalance)
What we
might do
Medication
Psychotherapy
Isolation,
abuse
Women’s
Shelter, social
support
Progress of treatment
Psychotherapy
100
90
80
70
60
50 Medication
40
30
20
10
0
1
Social support
2
3
5
6
7
8
The systems-oriented
view of the
Biopsychosocial
Model
World
Country
Village
Family
Relationships
PATIENT
Organ systems
Organs
Tissues
Cells
Cell components
Molecules
Engel GL: The clinical application of the biopsychosocial model.
Am J Psychiatry. 1980 May;137(5):535-44
ANTHRAX
What have we learned today?
Symptoms are common
 Occasionally their meanings change
and individuals seek health care
 Illness and disease are different
 The bio-psycho-social model is the key
for organizing the story

"It is more important to
know what kind of a
patient has a disease
than what kind of
disease a patient
has."
Sir William Osler, M.D., 1891