Subject: PSYCHIATRY 2 Lecturer: Michelle Marie Marinas M.

D Topic: Psychosomatic Medicine

Psychological Factors Affecting Medical Condition
 Two Basic Assumptions of Psychosomatic Medicine: 1. There is unity of mind and body (mind-body medicine) 2. Psychological factors must be taken into account when considering all disease states 3. In DSM-IV-TR -Psychological Factors Affecting Medical Conditions  Physical disorders caused by emotional or psychological factors  Mental or emotional disorders caused of aggravated by physical illness Exclusions: 1. Classic mental d/o’s that have physical symptoms as part of the disorder (eg., Conversion Disorder) 2. Somatization disorder 3. Hypochondriasis 4. Physical complaints associated with mental d/o ’s  DSM-IV-TR Diagnostic Criteria A. A GMC (coded on Axis III) is present B. Psychological Factors adversely affect the GMC: 1. Factors have influenced the course of the GMC as shown by temporal association between psychological factors and development or exacerbation of, or delayed recovery from, the GMC 2. Factors interfere with treatment of GMC 3. Factors constitute additional health risks for the individual 4. Stress-related physiological responses precipitate or exacerbate symptoms of GMC If more than one factor is present, choose the most prominent…  Mental Disorder affecting GMC  Psychological symptoms affecting GMC  Personality traits or coping style affecting GMC  Maladaptive health behaviors affecting GMC  Stress-related physiological response affecting GMC STRESS THEORY -A circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person. Walter Cannon: first systematic study on the relation of stress to disease Harold Wolff: physiology of GI tract correlate with emotional states

Hans Selye:   

General adaptation syndrome (3 phases) Alarm reaction Stage of resistance Stage of exhaustion  Acute and chronic responses

EUSTRESS(POSITIVE)  Coined by endocrinologist Hans Selye  Eu means “well” or “good” (Gr.)  Positive cognitive response to a stressor  Sense of meaning, hope or vigor  Depends on how an individual perceives the stress  Motivates, focuses energy  Within coping abilities  “exciting” DISTRESS(NEGATIVE)  Negative stress  When “good stress” becomes too much to bear or cope with  Tension builds  Seems to be no relief, no end in sight

Distress as High Risk Biopsychosocial Factors | Eustress----------------Distress | Psychological and Physical Symptoms *If the person is in distress for long periods, the person would be at high risk for developing psychological symptoms. A. Neurotransmitter Responses to Stress  Activate noradrenergic systems in the brain (locus ceruleus) and release catecholamines from ANS  Activate serotonergic systemsè increased serotonin turnover Endocrine Responses to Stress Corticotropin Releasing Factor (CRF) I Acts at anterior pituitary I Release of ACTH I Synthesis and release of glucocorticoids (fight or flight) B. Immune Response to Stress  Inhibition of immune functioning by glucocorticoids  Also, immune activation by other pathways  Also, profound immune activation by release of cytokines, which increase glucocorticoid effects C. Life Events  Life situation or event, favorable or unfavorable, often occurring by chance, generates challenges to which the person must adequately respond Holmes and Rahe Social Readjustment Scale:  200 or more life-change units increases risk D. Specific vs. Nonspecific Stress Factors  Specific personalities and conflicts – certain psychosomatic diseases  Meyer Friedman and Ray Rosenman – personality types Type A – coronary personality (more likely to get heart disease because of high stress lifestyle) Type B  Franz Alexander- unconscious conflicts and specific diseases  Peptic ulcer – dependency needs  Essential HPN – hostile impulses from which they feel guilty  Asthma – separation anxiety

SPECIFIC ORGAN SYSTEMS Gastrointestinal System A. Functional GI Disorders a. Anxiety can produce disturbances in GI function through central control mechanism or humoral effects (release of catecholamines) b. Vagus modulated by limbic system (emotions-gut pathway) c. Functional dysphagia, IBS, functional diarrhea B. Peptic Ulcer Disease a. Increased gastric acid secretion associated with psychological stress b. Higher vulnerability to H. pylori C. Ulcerative Colitis a. No generalizations about psychological mechanisms D. Crohn’s Disease Cardiovascular System A. Associated with depression a. Severe depression after CABG – increased risk of death B. Type A behavior pattern, anger, hostility a. Physiologic processes: reduced parasympathetic modulation of HR, increased circulation of catecholamines, increased coronary calcification, increased lipid levels C. Stress Management D. Cardiac arrhythmias and sudden cardiac death a. Acute emotions can stimulate arrhythmias E. Heart Transplantation a. Stages of adaptation elicit anxiety, depression, etc. b. Mood disorders F. Hypertension G. Vasovagal syncope a. Specific psychological triggers still unidentified Specific Psychiatric Conditions A. AIDS dementia B. AIDS mania C. Increased rates of MDD D. Psychiatric consequences of CNS injuries Respiratory System A. Asthma a. Dependency needs b. Greater use of corticosteroids, longer hospitalizations c. Personality traits: intense fear, emotional lability, sensitivity to rejection, lack of persistence in difficult situations B. Hyperventilation syndrome C. Chronic Obstructive Pulmonary Disease (COPD) a. Panic and anxiety disorders are co-morbidities Endocrine System A. Hyperthyroidism a. Nervousness, insomnia, lability of mood, dysphoria b. Pressured speech

c. Short attention span, impaired recent memory, exaggerated startle response d. Visual hallucinations, paranoid ideation, delirium B. Hypothyroidism a. Depressed mood, apathy, impaired memory b. Auditory hallucinations and paranoia (myxedema madness) C. Diabetes mellitus a. Dietary control - depression D. Adrenal Disorders  Cushing’s Syndrome  Adrenocortical hyperfunction from excessive secretion of ACTH or adrenal pathology (tumor)  Severe depression to elation  Clinical features of Cushing’s E. Hypercortisolism a. Fatigue, depressed mood b. Emotional lability, irritability, decreased libido, anxiety c. Social withdrawal F. Hyperprolactinemia a. Traumatic childhood experiences predispose to hyperprolactinemia b. Sexual dysfunctions: erectile disorder and anorgasmia Skin Disorders A. Atopic dermatitis (atopic eczema or neurodermatitis) a. Anxiety, depression b. Exacerbate atopic dermatitis by scratching behavior c. Depressive symptoms amplified itching behavior B. Psoriasis a. Lead to stress, which triggers psoriasis b. Cosmetic disfigurement and social stigma C. Psychogenic excoriation (psychogenic pruritus) a. Lesions caused by scratching or picking in response to an itch b. Resembles OCD: impulsive, ritualistic, repetitive, tension reducing D. Localized pruritus a. Pruritus ani - itching around the anus , condition results in a compelling urge to scratch b. Pruritus vulvae-vaginal itching E. Hyperhidrosis a. States of fear, rage and tension b. Increased sweat secretion on the palms, soles and axillae c. Anxiety phenomenon mediated by the ANS F. Urticaria a. Stressful life events and urticaria b. Stress – secretion of neuropeptides - vasodilation Musculoskeletal system A. Co-morbid psychiatric symptoms may be a. result of patient’s psychological response to the loss and discomfort imposed by the disease b. effect of disease process on CNS B. Rheumatoid Arthritis – chronic musculoskeletal pain from inflammation of the joints a. depression

C. Systemic Lupus Erythematosus (SLE) a. Recurrent episodes of destructive inflammation of several organs b. Highly unpredictable, incapacitating, potentially disfiguring D. Low back pain a. Excruciating pain, restricted movement, paresthesias, weakness or numbness b. Accompanied by fear, panic and anxiety c. Oftentimes debilitating E. Fibromyalgia a. Pain and stiffness of the soft tissues such as muscles, ligaments and tendons b. “trigger points”: local areas of tenderness c. Cervical and thoracic areas most commonly affected d. Fatigue, anxiety, insomnia e. Present in chronic fatigue syndrome and depressive d/o F. Headaches a. Psychological stress exacerbates headache, whether primary cause is physical or psychological G. Migraine (Vascular) and Cluster Headaches a. Functional disturbance in cranial circulation b. Stress is al precipitant at times c. Overly controlled perfectionists, unable to suppress anger H. Tension (Muscle Contraction) Headaches a. Emotional stress è prolonged contraction of head and neck muscles è constrict blood vessels b. Dull, aching pain, tightening band Medical Conditions that present with psychiatric symptoms A. Hyperthyroidism – irritability, pressured speech, psychosis B. Hypothyroidism - depression C. Hypoglycemia – anxiety, confusion, agitation D. Hyperglycemia – anxiety, agitation, delirium E. Brain neoplasms – personality changes F. Frontal lobe tumor – mood changes, impaired judgment G. Occipital lobe tumor – aura, visual hallucinations H. Temporal lobe tumor – olfactory hallucinations (smell) I. AIDS – progressive dementia, depression, psychosis J. Hyponatremia(low sodium ion concentration) – confusion, lethargy, personality changes K. Pancreatic cancer – depression, lethargy, anhedonia L. Multiple sclerosis – anxiety, euphoria, mania M. Hepatic encephalopathy – euphoria, disinhibition, psychosis, depression N. Pheochromocytoma – anxiety O. Wilson’s disease – mood disturbances, delusions, hallucinations P. Vitamin deficiencies END OF TRANSCRIPTION ___________
“Disease is a vital expression of the human organism. ” -Georg Groddeck -