PSYCHOSOMATIC MEDICINE

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PSYCHOSOMATIC MEDICINE

• Dr. YASER ALHUTHAIL
• Ass. Professor Consultant
• Consultation Liaison Psychiatry

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• 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.
• Integrates mind and body into a
  psychobiological unit to study psychological and
  biological processes as dynamic interacting
  systems.
• It emphasizes the unity of mind and body and
  the interaction between them.
• A holistic approach to medicine.

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• Two basic assumptions
• There is a unity of mind and body (reflected in
  the term mind-body medicine)
• 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.
  

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• 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.

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• 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

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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.

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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.

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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.

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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.

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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.

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• 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.

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• 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

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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.

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• 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)

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• The essential challenge in psychosomatic-psych
  obiological research is to delineate the
  mechanisms by which experiences cause certain
  types of physiological reactions that result in
  disease states.

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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 the hypothalamic-pituitary-a
  drenal (HPA) axis, 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).

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Gastrointestinal Conditions

• 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 is the most common.
• Brain-Gut axis
• Hypersensitivity of GI tract
• Role of stress

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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 patients conscious control.

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Somatoform Disorders

• Somatization disorder
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Body Dysmorphic Disorder

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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

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Consultation vs. consultation-Liaison

• Liaison model is based on an early
  detection strategy to identify potential
  problems.
• 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 patients
  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.

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MODELS OF COMORBIDITY
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
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TREATMENT FOR MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
TREATMENT FOR PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
SMOKING AND NICOTINE DEPENDENCE
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