SEMINAR ON MEDICAL CONDITIONS DUE

TO PSYCHOLOGICAL PROBLEMS-
HYPERTENSION, ULCERATIVE COLITIS,
MIGRAINE AND RHEMATOID ARTHRITIS

SUBMITTED TO: SUBMITTED BY:

Mrs.Jaysri Vaideeswari.K

Tutor M. Sc. Nursing 2nd year

College of Nursing College of Nursing

JIPMER JIPMER
 MEDICAL CONDITIONS DUE TO PSYCHOLOGICAL PROBLEMS-
HYPERTENSION, ULCERATIVE COLITIS, MIGRAINE AND RHEMATOID
ARTHRITIS

INTRODUCTION TO PSYCHOSOMATIC MEDICINE

The word Psychosomatic is derived from two words: “Psycho-Mind” and “Somatic-Related to
body.” It means relating to the interaction of mind and body. Psychosomatic medicine (PM) has had
ambiguous connotations in the past, alternatively “psychogenic” or “holistic,” but it is the latter
meaning that has characterized its emergence as a contemporary scientific and clinical discipline.

HISTORY
Psychosomatic disorders (a term coined by Heinroth in 1918) are those disorders in which
psychosocial factors are very important in causation. Broadly applied, this term can encompass all
physical illnesses. A narrow but more practical definition would include those physical disorders
which are either initiated or exacerbated by the presence of meaningful psychosocial environmental
stressors. ICD-10 lists these disorders under the category of Psychological or behavioural factors
associated with disorders or diseases classified elsewhere.
Franz Alexander, the Father of Psychosomatic Medicine, initially described the seven classical
psychosomatic illnesses.
CLASSICAL SEVEN PSYCHOSOMATIC DISORDERS:
▪ Bronchial asthma
▪ Ulcerative colitis
▪ Peptic ulcer
▪ Neurodermatitis
▪ Thyrotoxicosis
▪ Rheumatoid arthritis
▪ Essential hypertension

His specificity hypothesis stated that if a specific environmental stressor or emotional conflict
occurs, it results in a specific illness in a genetically predetermined organ.
DSM-IV-TR states
Psychological factors can influence the course of the general medical conditions, which can be
inferred by a close temporal association between the factors and the development or exacerbation of
or delayed recovery from the medical conditions
Several types of psychological factors are implicated by the DSM-IV TR as those that can affect
the general medical conditions. They include
 Mental disorders
 Psychological traits or coping styles
 Personality traits or coping styles
 Maladaptive health behaviours
 Stress related physiological response
 Other or unspecified psychological factors

The DSM-IV TR diagnostic criteria for psychological factors affecting Medical conditions
 A general medical conditions ( coded on Axis III) is present
 The factors have influenced the course of the general medical conditions is one of the
following ways:
• The factors have influenced the course of the general medical conditions as shown by
the close temporal association between the psychological factors and the
development or exacerbation of or delayed recovery from the general medical
conditions.
• The factors interfere with treatment of the general medical conditions.
• The factors consitute additional health risk for the individual
• Stress related physiological response precipitate or exacerbate symptoms of the
general medical conditions

Specify type of psychological factors:

• Mental disorders (eg.axis I disorder such as major depressive delaying recovery from a
myocardial infarction)
• Psychological symptoms (eg.depressive symptoms delaying recovery from surgery, anxiety
exacerbating asthma)
 • Personality traits or coping styles (e.g. pathological denial of the need for surgery in a
patients with cancer, hostile pressured behaviour contributing to cardiovascular disease).
• Maladaptive health behaviour (e.g. overeating, lack of exercise, unsafe sex)
Stress related physiological response (e.g. stress related exacerbations of ulcer,
hypertension, arrhythmias or tension headache)
• Other or unspecified psychological factors (eg.no. interpersonal, cultural or religious factors)

HISTORICAL ASPECTS
For more than a century, physicians have agreed that in some disorders an interaction exists
between emotional and physical factors. Four general types of reaction to stress have been identified
and they parallel Peplau’s four levels of anxiety. These reactions are:
▪ The normal reaction (mild anxiety), in which there is increased alertness and a mobilization
of defences for action.
▪ The psychophysiological reactions (moderate anxiety), in which the anxiety is so great that
the defences become ineffective and neurotic symptoms develop.
▪ The psychotic reactions (panic anxiety), in which loss of control results in misperception of
the environment.
Historically, mind and body have been viewed as 2 distinct entities, each subject to different
laws of causality, however medical research shows that change is occurring. Research
associated with biological functioning is being expanded to include the psychological and
social determinates of health and disease. This psychobiological approach to illness reflects
a more holistic perceptive and one that promotes concern for helping clients to achieve
optimal functioning.

CLASSIFICATION OF DISORDERS:-
ICD -10 CLASSIFICSATION
F54: Psychological and behavioural factors associated with disorders or diseases
classified elsewhere:

This category should be used to record the presence of psychological or behavioral factors thought
to have influenced the manifestation, or affected the course, of physical disorders that can be
classified using other chapters that can be classified using other chapters of ICD 10. Any resulting
mental disturbances are usually mild and often prolonged (such as worry, emotional conflict,
apprehension) and do not of themselves justify the use of any of the categories described in the rest
of this book. An additional code should be used to identify the physical disorder. (In the rare
instances in which an overt psychiatric disorder is thought to have caused a physical disorder, a
second additional code should be used to record the psychiatric disorder).

ICD-11 CLASSIFICATION
(BlockL1-6E2)
6E40 - Psychological or behavioural factors affecting disorders or diseases
classified elsewhere
Psychological and behavioural factors affecting disorders or diseases classified elsewhere are
those that may adversely affect the manifestation, treatment, or course of a condition classified in
another chapter of the ICD. These factors may adversely affect the manifestation, treatment, or
course of the disorder or disease classified in another chapter by: interfering with the treatment of
the disorder or disease by affecting treatment adherence or care seeking; constituting an additional
health risk; or influencing the underlying pathophysiology to precipitate or exacerbate symptoms or
otherwise necessitate medical attention. This diagnosis should be assigned only when the factors
increase the risk of suffering, disability, or death and represent a focus of clinical attention, and
should be assigned together with the diagnosis for the relevant other condition.
6E40.0 : Mental disorder affecting disorders or diseases classified elsewhere

6E40.1 : Psychological symptoms affecting disorders or diseases classified elsewhere

6E40.2 : Personality traits or coping style affecting disorders or diseases classified elsewhere

6E40.3 : Maladaptive health behaviours affecting disorders or diseases classified elsewhere

6E40.4 : Stress-related physiological response affecting disorders or diseases classified elsewhere

All diagnostic requirements for Psychological or behavioural factors affecting disorders
or diseases classified elsewhere are met. The individual exhibits stress related physiological
responses that adversely affect the manifestation, treatment, or course of a disorder or disease
classified in another chapter (e.g., stress-related exacerbation of ulcer, hypertension,
arrhythmia, or tension headache)
6E40.Y: Other specified psychological or behavioural factors affecting disorders or diseases
classified elsewhere
6E40.Z: Psychological or behavioural factors affecting disorders or diseases classified elsewhere,
unspecified

TYPES OF PSYCHOPHYSIOLOGICAL DISORDERS

Cardiovascular disorders
• Coronary heart disease
• Essential hypertension
• Migraine headache
• Angina pectoris
• Myocardial infarction
Gastrointestinal disorders
• Peptic ulcer /stress ulcer
• Irritable bowel syndrome
• Ulcerative colitis
• Esophageal reflux
• Crohn’s disease
• Obesity
• Anorexia nervosa ‘
• Eating disorder
Endocrinal disorders
• Diabetes mellitus
• Hyperthyroidism
• Pre-menopausal symptoms
Musculoskeletal disorder
• Back ache
• Rheumatoid arthritis
Immune disorders
• Viral infections
• Systemic lupus erythematous
Respiratory disorders
• Bronchial asthma
• Hyperventilation
Skin disorders
• Neurodermatitis
• Psoriasis
• Alopecia
• Eczema
• Urticaria
• Acne vulgaris
Genitourinary disorder
• Chronic prostatitis
• Menstrual disorders
• Amenorrhoea
• Menopause
• Dysmenorrhoea
Miscellaneous
• Headache
• Cancer
• Sleep disorders
• Tinnitus
• Hysteria
• CNS disorders
• Hypochondriasis
• Visual disturbances
• Accident proneness
DYNAMICS OF PSYCHOPHYSIOLOGICAL DISORDERS

Precipitating event or stressors

Cognitive appraisal

Primary response

Threat to biological integrity or self -

concept

Secondary response

Defective usage of coping strategies

Quality of response

Anxiety ( Mild, severe , panic )

Adaptive behaviour by usages of Maladaptive responses resulting

coping strategies in behavioural deviations

Psychophysiological Psychoneurotic disorders e.g. somatization Psychotic responses e.g.

disorders disorders like pain hypochondriasis ,
panic psychosis
conversion disorder
ETIOLOGY OF PSYCHO-PHYSIOLOGICAL DISORDERS:
A. Biological Factors

• Genetic Factors: It was observed that to some extent specific genetic factors are responsible
for this disorder- Asthma, ulcers, migraine and hypertension in greater frequencies have
been reported in close relatives of the patients.
• Differences in autonomic reactivity: This disorder is the outcome of individual’s primary
reaction tendencies to stress different children reacts differently to some stress by developing
specific types of physiological disorder like fever, indigestion, sleep disturbances etc.
• Somatic Weakness: Some studies stated that psychosomatic disorders occur specially in the
weak of interior organ of the body which is produced usually due to heredity, illness and
trauma.
B. Psychosocial Factors

• Personality Factors: Individuals attitude towards stressful situation and the coping pattern
which he adopts are the reason in the development of psycho-physiological disorders.
Though personality factors are not solely accountable for the total cause of psycho-
physiological disorders.
• Interpersonal relationship: Some studies indicate the relationship between pathogenic
family patterns to psychophysical illness. Marital unhappiness, separation, divorce, death of
near 5 one's, and other stressful interpersonal relationship may influence psychophysical
logical disorders.
C. Socio-cultural Factors

• Psycho-physiologic disorders may vary in incidence from culture to culture and society to
society. It was observed that psychosomatic disorders are rarely found in primitive people
but with the time of modernization it is frequently occurred in developed societies. Some
have the idea that Socio-Economic Statues (SES) may be a reason behind this disorder
 BIO PSYCHOSOCIAL MODEL FOR PSYCHOSOMATIC ILLNESS:

George Engel in 1977, described a bio psychosocial model to explain the complex interaction
between biological, psychological and social spheres resulting in a psychosomatic illness. This
viewpoint has become very popular and is now almost integral to depicted in a .Beginning from
seven classical psycho somatic illnesses of Alexander, number of these illnesses continued to
increase as their biopsychosocial causation became more evident and clear. At present, the list of
psychosomatic illnesses is virtually endless as it is not difficult to imagine the effect of psychosocial
factors on most illnesses.

Major conceptual trends in the etiology of psychosomatic medicine

I. PSYCHOANALYTIC

Sigmund Freud (1900): Somatic involvement occurs in conversion hysteria, which is psychogenic in
origin—e.g., paralysis of an extremity. Conversion hysteria always has a primary psychic cause and
meaning; i.e., it represents the symbolic substitutive expression of an unconscious conflict. It involves
organs innervated only by the voluntary neuromuscular or the sensorimotor nervous system. Psychic
energy that is dammed up is discharged through physiological outlets.
Sandor Ferenczi (1910): The concept of conversion hysteria is applied to organs innervated by the
autonomic nervous system; e.g., the bleeding of ulcerative colitis may be described as representing a
specific psychic fantasy.

George Groddeck (1910): Clearly organic diseases, such as fever and hemorrhage, are held to have
primary psychic meanings; i.e., they are interpreted as conversion symptoms that represent the
expression of unconscious fantasies.

Franz Alexander (1934, 1968): Psychosomatic symptoms occur only in organs innervated by the
autonomic nervous system and have no specific psychic meaning (as does conversion hysteria) but are
end results of prolonged physiological states, which are the physiological accompaniments of certain
specific unconscious repressed conflicts. Presented first conceptualization of the biopsychosocial
model.

Helen Flanders Dunbar (1936): Specific conscious personality pictures are associated with specific
psychosomatic diseases, an idea similar to Meyer Friedman's 1959 theory of the type A coronary type.

Peter Sifneos, John C. Nemiah (1970): Elaborated the concept of alexithymia. Developmental arrests
in the capacity and the ability to express conflict-related affect result in psychosomatic symptom
formation. Concept of “alexithymia” modified later by Stoudemire, who advocated the term
“somatothymia” emphasizing cultural influences on use of somatic language and somatic symptom to
express affective distress.

II. PSYCHOPHYSIOLOGICAL

Walter Cannon (1927): Demonstrated the physiological concomitants of some emotions and the
important role of the autonomic nervous system in producing those reactions. The concept is based on
Pavlovian behavioural experimental designs.

Harold Wolff (1943): Attempted to correlate life stress to physiological response, using objective
laboratory tests. Physiological change, if prolonged, may lead to structural change. He established the
basic research paradigm for the fields of psychoimmunology, psychocardiology, and psycho
neuroendocrinology.
 Hans Selye (1945): Under stress a general adaptation syndrome develops. Adrenal cortical hormones
are responsible for the physiological reaction.

Meyer Friedman (1959): Theory of type A personality as a risk factor for cardiovascular disease.
The basic concept was introduced by Helen Flanders Dunbar as early as 1936.

Robert Ader (2007): Beginning in the 1970s, established the basic concepts and the research
methods for the field of psychoneuroimmunology.

III. SOCIOCULTURAL

Karen Horney (1939), James Halliday (1948): Emphasized the influence of the culture in the
development of psychosomatic illness. They thought that culture influences the mother, who, in turn,
affects the child in her relationship with the child—e.g., nursing, child rearing, anxiety transmission.

Thomas Holmes, Richard Rahe (1975): Correlated the severity and the number of recent stressful
life events with the likelihood of disease.

IV. SYSTEMS THEORY

Adolph Meyer (1958): Formulated the psychobiological approach to patient assessment that
emphasizes the integrated assessment of developmental, psychological, social, environmental, and
biological aspects of the patient's condition. Basic concept of the biopsychosocial model is implicit
in his approach.

Zbigniew Lipowski (1970): A total approach to psychosomatic disease is necessary. External

(ecological, infectious, cultural, environmental), internal (emotional), genetic, somatic, and
constitutional factors as well as past and present history are important and should be studied by
investigators working in the various fields in which they are trained.

George Engel (1977): Coined the term “biopsychosocial” derived from general systems theory and
based on conceptual ideas introduced much earlier by Alexander and Meyer.

Leon Eisenberg (1995): Contemporary psychiatric research demonstrates that the mind–brain
responds to biological and social vectors while being jointly constructed of both. Major brain
pathways are specified in the genome; detailed connections are fashioned by, and consequently
reflect, socially mediated experience in the world.

V. 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. In the 1920s, Walter Cannon (1871-1945)
conducted the first systematic study of the relation of stress to disease. He demonstrated that
stimulation of the autonomic nervous system, particularly the sympathetic system, readied the
organism for the "fight-or-flight" response characterized by hypertension, tachycardia, and
increased cardiac output. In the 1950s, Harold Wolff (1 898-1 962) observed that the physiology of
the gastrointestinal (GI) tract appeared to correlate with specific emotional states. Hyper function
was associated with hostility and hypo function with sadness.

Hans Selye (1907-1 982) developed a model of stress that he called the general adaptation
syndrome. It consisted of three phases:
▪ The alarm reaction
▪ The stage of resistance, in which adaptation is ideally achieved; and
▪ The stage of exhaustion, in which acquired adaptation or resistance may be lost.
He considered stress a nonspecific bodily response to any demand caused by either pleasant or
unpleasant conditions. Selye believed that stress, by definition, need not always be unpleasant. He
called unpleasant stress distress. Accepting both types of stress requires adaptation. The body reacts
to stress-in this sense defined as anything (real, symbolic, or imagined) that 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.

Neurotransmitter Responses to Stress:

Stressors activate noradrenergic systems in the brain (most notably in the locus ceruleus) and cause
release of catecholamine’s 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:

In response to stress, CRF is secreted from the hypothalamus into the hypophysial-pituitary-portal
system. CRF acts at the anterior pituitary to trigger release of adrenocorticotropic hormone (ACTH).
Once ACTH is released, it acts at the adrenal cortex to stimulate the synthesis and release of
glucocorticoids. Glucocorticoids themselves have myriad effects within the body, but their actions
can be summarized in the short term as promoting energy use, increasing cardiovascular activity (in
the service of the flight-or-fight response), and inhibiting functions such as growth, reproduction,
and immunity.
Immune Response to Stress:
Part of the stress response consists of the inhibition of immune functioning by glucocorticoids.
Immune activation also occurs, including the release of humoral immune factors (cytokines) such as
interleukin-I (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.
Cardiovascular Disorders:
Cardiovascular disorders are the leading cause of death in the United States and the industrialized
world. Depression, anxiety, type A behavior, hostility, anger, and acute mental stress have been
evaluated as risk factors for the development and expression of coronary disease.
Negative affect in general, low socioeconomic status, and low social support have been shown to
have significant relationships with each of these individual psychological factors, and some
investigators have proposed these latter characteristics as more promising indices of psychological
risk. Data from the Normative Aging Study on 498 men with a mean age of 60 years demonstrate a
dose-response relationship between negative emotions, a combination of anxiety and depression
symptoms, and the incidence of coronary disease. Severe depression 6 months after coronary artery
bypass graft (CABG) surgery or persistence of moderate depression symptoms beginning before
surgery at 6-month postoperative follow-up predicts an increased risk of death over 5-year follow-
up.

Type A Personality: When personality characteristics of a patient with coronary artery disease
(CAD) are examined, there may be preponderance of a certain type of personality traits, collectively
described as coronary prone Type A behaviour by Friedman and Rosenman.

The relationship between a behavior pattern characterized by easily aroused anger, impatience,
aggression, competitive striving, and time urgency (type A) and CAD found the type A pattern to be
associated with a nearly twofold increased risk of incident MI and CAD-related mortality. Group
therapy to modify a type A behavior pattern was associated with reduced reinfarction and mortality
in a 4.5-year study of patients with prior MI

 Submissiveness has been found to be protective against CAD risk in women.

 Adrenergic receptor function is down regulated in hostile men.

 Chronic overproduction of catecholamine’s caused by chronic and frequent anger.

Time Urgency

There is always a hurry to finish the task at hand. This is extended even to day-to-day routine
activities such as eating, bathing. Speech is usually hurried and the psychomotor activity is often
increased.

Excessive Competitiveness and Hostility

There is a need to always win, with mistrust for other people’s motives. Chronic struggle to achieve
a large number of tasks, working against the limits of time available and/or other people in the
surrounding environment. In contrast, Type B behaviour is just the opposite, characterised by a
relaxed unhurried attitude and less vigorous attempts to achieve a goal. Some studies report that
persons with Type B personality are paradoxically more successful than those with Type A
personality. It is important to note that not all patients with CAD present with Type A personality
traits.

CHARACTERISTICS OF TYPE A PERSONALITY INCLUDE:

 Having easily aroused hostility that is usually kept under control but flares up unexpectedly,
often when others would consider it as unwanted.
 Being very aggressive, very ambitious, concentrating almost exclusively on his/her career.
 Having no time for hobbies, and during any leisure time, feeling guilty just relaxing as if
wasting time.
 Seldom feeling satisfied with accomplishments; always feeling must do more.
 Measuring achievements in numbers produced and money earned
 Continually struggling to achieve and feeling there is never enough time
  Appearing to be very extroverted and social; often dominating conversation; having an
outgoing personality but often concealing a deep seated insecurity about one’s own worth.
 Experiencing driving ambition and the need to win.
 According to Denollet, (1997) CHD is associated with type D personality (distressed
personality). Individuals with type D personality have a tendency to experience negative
emotions such as anger, anxiety, depression, worry, and hopelessness and the inability to
express feelings in social situations.

ESSENTIAL HYPERTENSION

Definition
It is the persistent evaluation of blood pressure for which there is no apparent cause or associated
underlying disease (Fanning & Lewis, 2003). It is a major cause of cerebrovascular accident
(Stroke), cardiac disease, and renal failure.

Epidemiological statistics

Approximately 30% of the adult population in the United States is hypertensive. (American Heart
Association, 2005). Because hypertension is often asymptomatic it is estimated that 30% of persons
with hypertension do not know they have it.

The disorder is more common in men than in women and is twice as prevalent in the African
American population as it is in the white population.

Prevalence

More than 60 million Americans have hypertension. The prevalence among whites is about 15 per
cent, but is over 25 per cent in the African-American population.

Of persons with hypertension, 95 per cent have primary, or idiopathic, hypertension. The remaining
5 per cent have secondary hypertension, due most commonly to renal disease, renovascular disease,
steroid excess, oral contraceptives, or hyperparathyroidism

Patients with hypertension, in general, have a more prolonged vasoconstrictive response to

psychological stress than patients with normotension
 Environmental factors also clearly play a role in hypertension. For example, populations who live in
stable, safer, and rural environments have fewer individuals with hypertension than those in urban
environments with higher crime rates and unstable social structures

Predisposing factors
▪ Biological influences

Family history of hypertension: Individual with family history of hypertension are at higher risk
for developing hypertension than those who do not.

▪ Physiological influences
Physiological influences that has been influence’s that have been hypothesized include imbalance
in of circulating vasoconstrictors and vasodilators, increased sympathetic nervous system activity
resulting in increased vasoconstrictions and impairment of sodium and water excretion.
▪ Psychological influence

There is correlation between suppressed anger and hypertension. Some psychoanalysis believe
this may be associated with childhood rearing that forbade expression of angry feelings

▪ Environmental factors
Individual with hypertension should not smoke
▪ Psychosocial influences
✓ Karren and associates (2002) report on studies that suggest there is a correlation between
suppressed anger and hypertension.
✓ Some psychoanalyst believes this may be associated with childhood rearing that forbade
expression of angry feelings. Several studies showed consistent results of a significant
relationship between suppressed anger and elevated blood pressure
▪ Other conditions
Other conditions that may contribute to hypertension are obesity and cigarette smoking.

Signs and symptoms

▪ Most commonly hypertension produces no symptoms, particularly in the early stages. When
symptoms do occur, they may include
 ▪ Headache
▪ Vertigo
▪ Flushed face
▪ Spontaneous nosebleed
▪ Blurred vision.
▪ Chronic progressive hypertension may reveal signs and symptoms associated with specific
organ system damage.

Therapeutic interventions

Lifestyle modifications
 Weight control or reduction to attain a body mass index of 18.5 to 24.9 kg/m2
 Dietary Approaches to Stop Hypertension (DASH) eating plan: increased fruits, vegetables, and
low-fat dairy products that are rich in calcium and potassium
 Sodium restriction (less than 2.4 g daily)
 Aerobic exercise at least 30 minutes on most days
 Alcohol moderation (no more than one drink daily for women, two for men)

Drug therapy

Prehypertension: Only for compelling indications

 Stage 1 hypertension: thiazide diuretics for most; may consider ACEIs, ARBs, CCBs, BBs
 Stage 2 hypertension: second drug added to thiazide diuretic for most

Other interventions: smoking cessation, relaxation modalities such as biofeedback and imagery;
antianxiety agents

Psychological intervention

 Relaxation techniques:

This is one of the most important methods aimed at reducing the basal generalised anxiety or
inner sense of restless ness. The common techniques include:

1. Jacobson’s progressive muscular relaxation (PMR) technique

2. Yoga
 3. Autohypnosis
4. Transcendental meditation
5. Biofeedback.
6. Behaviour modification techniques.
7. Individual psychotherapy, usually cognitive behaviour therapy.
8. Group therapy

Dietary modifications

Two effective non pharmacological modalities for the reduction of elevated blood pressure include
weight reduction and sodium restriction. It may be necessary for the individual who is on diuretic
therapy to ensure that there is sufficient intake of potassium, either through diet or with
supplements. It is also important to decrease intake of caffeine, alcohol and saturated fats.

Physical exercise

Increased physical activity (eg.30 to 45 min of brisk walking three to five times a week) have
been shown to lower blood pressure in some hypertensive individual. Exercise prevent and
controls hypertension by reducing weight, decreasing peripheral resistance and decreasing the
body fat. Caution with weight bearing exercise as acute rise in blood pressure can occur

HEADACHES
Headaches are the most common neurological symptom and one of the most common medical
complaints.

▪ Every year about 80 percent of the population has at least one headache, and 10 to 20 percent
go to physicians with headache as their primary complaint. Headaches are also a major cause of
absenteeism from work and avoidance of social and personal activities
▪ Most headaches are not associated with significant organic disease; many persons are
susceptible to headaches at times of emotional stress. Moreover, in many psychiatric disorders,
including anxiety and depressive disorders, headache is frequently a prominent symptom
MIGRAINE / VASCULAR HEADACHE

▪ Migraine (vascular) headache is a paroxysmal disorder characterized by recurrent unilateral

headaches, with or without related visual and gastrointestinal disturbances (e.g., nausea,
vomiting, and photophobia)
▪ The word migraine comes from the Greek word hemikranion meaning half of the cranium. In
Migraine headache, pain usually affects one side of the head. Pain most commonly originates in
the muscles of the face, neck and head; the blood vessels dilate and the durameter. The blood
vessel dilate and become congested with blood. Pain results from the exertion of pressure on
nerves that lie in or around these congested blood vessels.
▪ Migraines are probably caused by a functional disturbance in the cranial circulation. Migraines
can be precipitated by cycling estrogen, which may account for their higher prevalence in
women. Stress is also a precipitant, and many persons with migraine are overly controlled,
perfectionists, and unable to suppress anger.

Epidemiological statistics

▪ Migraine headache can occur at any age but commonly begin in persons between age 16 and
30 years
▪ They are more common in women than in men and often are associated with various phases
of the menstrual cycle.
▪ Approximately 5% of the general population suffers from migraine headache.

Predisposing factors
Biological Influence

▪ Functional disturbance in the cranial circulation.

▪ Can be precipitated by cycling estrogen, which may account for their higher prevalence in
women.
▪ Some foods, beverages and drugs individuals like caffeine, chocolate, cheese, vinegar, organ
meats, alcoholic beverages, etc can precipitate migraine in certain.

Psychological influences
▪ Stress is also a precipitant, and many persons with migraine are overly controlled,
perfectionists, and unable to suppress anger. Cluster headaches are related to migraines.
▪ They are unilateral, occur up to eight times a day.

Psychological influences:

Certain characteristics have been identified as the ‘the migraine personality’. Migraine sufferers
have been discussed as

▪ Meticulously neat and tidy

▪ Compulsive
▪ Very hard workers
▪ Intelligent, exacting and place a high premium on success
▪ Delegation of responsibility is difficult for them 4as they feel no one can perform the task as
well as they can
Emotions play an important role in precipatig the migraine headache:
▪ An individual experiencing emotional stress may develop migraine headache in response to the
secondary gain one receives from the sick role. Migraine headache therefore may provide a means
to escape from dealing with stressful situations.
▪ Other individual’s experiences migraine attacks only after the emotionally distressing event has
passed or lessened. This has been called ‘let-down’ headache and can be one of the influncitial
factors in provoking the weekend or holiday migraine, when the anxiety has been relieved and the
individual finally relaxes.

Signs and symptoms:

The classic migraine headache occurs in 2 distinctive phases: prodromal phase and headache phase

In the prodromal phase, which may begin from minutes to day before the actual pain of headache,
the individual may experiences

 Visual disturbances
 Weakness and numbness on one side of the body
 Mental confusion
  Irritability
 Fatigue
 Sweating’s and
 Dizziness

The headache phase:

 Pain on one side of the head

 As pain intensifies it may spread to the other side of the body
 Ache is frequently dull, deep and throbbing and often begins in the forehead, jaw, ear, or in
or around an ear or temple.

Symptoms that accompany the headache:

 Nausea
 Vomiting
 Mental cloudiness
 Total body achiness
 Abdominal pain
 Chills
 Cold hands and feet

Duration: Pin from the migraine headache may last from 4 to 72 hours after which sore
muscles, total body exhaustion and a continued mild mental cloudiness may persist for days.

Treatment

Pharmacotherapy
▪ Migraines and cluster headaches are best treated during the prodromal period with ergotamine
tartrate (Cafergot) and analgesics.
▪ Prophylactic administration of propranolol or verapamil (Isoptin) is useful when the headaches
are frequent.
▪ Sumatriptan (Imitrex) is indicated for the short-term treatment of migraine and can abort attacks.
SSRIs are also useful for prophylaxis.
▪ Pharmacological intervention may be with a diuretic, beta-blocker, calcium channel blocker, or
angiotensin converting enzyme (ACE) inhibitor.
▪ Once migraine headache has begun , physicians will administer an injection of a narcotics such
as meperidine or codeine which blocks the pain and allows the individual to sleep until the
attacks subsides

Supportive psychotherapy

▪ Supportive psychotherapy, during which the individual is encouraged to express honest feelings,
particularly anger, May also be helpful.

Other Treatments

 Cold compresses to the head and neck

 Bed rest in quit , darkened room
 Application of pressure to the temples
 Head to neck and shoulder muscles that have contracted in response to headache pain

Relaxation therapy

▪ Rhythmic breathing
▪ Deep breathing
▪ Visualized breathing
▪ Progressive muscle relaxation
▪ Relax to music
▪ Mental imagery relaxation

Positive statements to be practised

▪ Let go of things, i cannot control

▪ I am healthy, vital and strong
▪ All my need are met
▪ I am completely and utterly safe
▪ Everyday in every way i am getting stronger
▪ Hypnosis
▪ Biofeedback
▪ Cognitive behaviour therapy

TENSION/ MUSCLE CONTRACTION HEADACHE

Emotional stress is often associated with prolonged contraction of head and neck muscles, which
over several hours may constrict the blood vessels and result in ischemia. A dull, aching pain,
sometimes feeling like a tightening band, often begins sub-occipitally and may spread over the head.

 The scalp may be tender to the touch and, in contrast to a migraine, the headache is usually
bilateral and not associated with nausea, or vomiting.

 Tension headaches are frequently associated with anxiety and depression and occur to some
degree in about 80 percent of persons during periods of emotional stress. Tense, high-strung,
competitive personalities are especially susceptible to the disorder

 In the initial stage, persons may be treated with antianxiety agents, muscle relaxants, and
massage or heat application to the head and neck; antidepressants may be prescribed when
an underlying depression is present.

 Psychotherapy is an effective treatment for persons chronically affected by tension

headaches. Learning to avoid or cope better with tension is the most effective long-term
management approach.

RHEUMATOID ARTHRITIS

Definition
Rheumatoid arthritis is a disease characterized by chronic musculoskeletal pain arising from
inflammation of the joints. The disorder's significant causative factors are hereditary, allergic,
immunological, and psychological.

Stress can predispose patients to rheumatoid arthritis and other autoimmune diseases by immune
suppression
  Depression is comorbid with rheumatoid arthritis in about 20 percent of individuals. Those
who get depressed are more likely to be unmarried, have a longer duration of illness, and
have a higher occurrence of medical comorbidity

 Individuals with rheumatoid arthritis and depression commonly demonstrate poorer

functional status, and they report more often painful joints, pronounced experience of pain,
health care use, bed days, and inability to work than do patients with similar objective
measures of arthritic activity without depression.

Epidemiological statistics
 It is more prevalent in women than in men by a ratio of 2:1 or 3:1
 It affects approximately 1 to 3% of the population of the United States with an estimated
200,000 cases diagnosed annually
 Depression is comorbid with rheumatoid arthritis in about 20% of individuals.

Predisposing factor

Biological influences

 Heredity

Heredity appears to be influential in the predisposition to rheumatoid arthritis. The serum proteins
rheumatoid factor is found in at least half of people with rheumatoid arthritis and frequency in their
close relatives

 Immunological

An additional theory postulates that rheumatoid arthritis may be the result of the dysfunctional
immune mechanism initiated by an infectious process, although the causative agents is yet to be
identified. In such an instances, antibodies that form in keeping with a normal reaction to infection
become directed instead against the self in an autoimmune responses that results in tissue damage.

Psychological Factors in Rheumatoid Arthritis

 Research suggesting that stressful life events play a role in the development or onset of RA
and other autoimmune diseases
  Depression appears to have an adverse effect on outcome in RA, aggravating chronic pain,
increasing healthcare use, and increasing social isolation

 A recent large longitudinal study found depression to be an independent risk factor for
mortality in patients with RA

 Passive, avoidant, emotional coping strategies(e.g., wish-fulfilling fantasy, self-blame)are

associated with poorer adjustment to illness in RA compared with active, problem focused
coping

Clinical manifestations
 Stiffness

 Tenderness

 Pain on motion

 Swelling

 Deformity

 Limitation of motion

 Extra-articular manifestations

 Rheumatoid nodules

Pharmacologic management
▪ (NSAID) Nonsteroidal anti-inflammatory drug such as ibuprofen, naproxen , indomethacin
▪ Disease modifying antirheumatoid drugs (DMARDs)
These drugs refer to a second line of defense, when NSAIDs are deemed ineffective.
DMARDs include hydroxychloroquine, gold salts, penicilillamine etc.
▪ Corticosteroids: Low dose prednisolone is used as a bridge to carry clients from
unsuccessful NSAIDs therapy until they experience the benefits of the slower acting
DMARDs.

Surgical treatment:
▪ Various surgical treatments are available for clients with rheumatoid arthritis.
 ▪ Synovectomy is performed to relieve pain and maintain muscle and joint balance.
▪ Joint fusion may provide stability to a joint and decrease deformity.
▪ Spinal fusion may be necessary to treat subluxation.
▪ Total joint replacement is performed to restore motion to a joint and function to the muscles,
ligaments and other soft tissue structures that control a joint.

Therapy

▪ Relaxation therapy
▪ Biofeedback
▪ Cognitive behaviour therapy
▪ Coping skills training

Psychological treatment:

▪ Psychotherapy and prompt recognition and treatment of psychiatric morbidity may help
clients cope and adapt to this condition. A client’s initial reaction to the diagnosis of
rheumatoid arthritis depends on the degree of incapacity at the time and the immediate
threat to his or her lifestyle.
▪ Depression may need to be treated separately.
▪ Clients should be encouraged to function as independently as possible. The focus on cure
should be deflected to a focus on control of the disease and prevention of disability

ULCERATIVE COLITIS
 Ulcerative colitis is an inflammatory bowel disease affecting primarily the large intestine. It
is a chronic inflammatory ulcerative disease of the colon usually associated with bloody
diarrhoea. The cause of ulcerative colitis is unknown.

 The predominant symptom of ulcerative colitis is bloody diarrhea. Extracolonic

manifestations can include uveitis, iritis, skin diseases, and primary sclerosing cholangitis.
Diagnosis is made mainly by colonoscopy or proctoscopy. Surgical resection of portions of
the large bowel or entire bowel can result in cure for some patients.
Epidemiological statistics
▪ The prevalence rate in the United States is estimated at 70to 150 per 100,000 population
▪ It can occur at any age but is more prevalent between the ages of 15 to 35 years.
▪ Ulcerative colitis affects male and female equally.
▪ The disease is more common in Caucasians than in African Americans and Asian
Americans.
▪ There is a higher incidence of ulcerative colitis in the Jewish population.

Predisposing factors
Biological Influences:

▪ Genetic Factor
A genetic factor may be involved in the development because individuals who have a family
member with ulcerative colitis are at greater risk than the general population.
▪ Autoimmune
The possibility that ulcerative colitis may be an autoimmune disease has generated a great
deal of research interest. High rates of anticolon antibodies are found in relatives of
ulcerative colitis clients.

Psychosocial influences:
▪ Predominance of obsessive compulsive traits. They are neat, orderly, and punctual and have
difficulty expressing anger.
▪ A pathological mother child relationship resulting in feelings of helplessness and
hopelessness has also been implicated.
▪ Stressful life events or psychological trauma.
▪ The altered immune status that accompanies psychological stress may be an influencing
factor in predisposed individuals.

Clinical manifestations
 Abdominal pain

 Bloody diarrhea
  Fatigue

 Weight loss

 Loss of appetite

 Rectal bleeding

 Loss of body fluids and nutrients

 Anemia caused by severe bleeding

 Generalized manifestation include fever, anorexia, weight loss, nausea and vomiting.

 During exacerbation of illness, anemia and elevated white cells cell count are common.

 The ulcers may bleed or perforate forming scar tissue as it heals.

Psychotropic treatment
Psychotropic drug use is common in the treatment of a variety of GI disorders. Psychotropic drug
treatment in patients with GI disease is complicated by disturbances in gastric motility and
absorption, and metabolism is related to the underlying GI disorder. Many GI effects of
psychotropic drugs can be used for therapeutic effects with functional GI disorders

 Most of the psychotropic agents are metabolized by the liver. Many of these agents can be
associated with hepatotoxicity. When acute changes in liver function tests occur with TCAs,
carbamazepine (Tegretol), or the antipsychotics, it may be necessary to discontinue the
drugs.

 During periods of discontinuation, lorazepam (Ativan) or lithium (Eskalith) can be used,

because they are excreted by the kidney.

 Electroconvulsive therapy (ECT) could also be used in the patient with liver disease

Therapeutic interventions

Dietary management

▪ During acute episode: low-residue diet progressing to regular diet

 ▪ Maintenance: high-protein, high-calorie diet; raw bran may be effective in controlling bouts
of diarrhoea and constipation; avoidance of food allergens, especially milk
▪ Unrestricted fluid intake if tolerated

Pharmacologic management

Antiemetics, anticholinergic, corticosteroids, antibiotics, sedatives, analgesics, tranquilizers, and

antidiarrheal:

▪ Anti-inflammatories (e.g., mesalamine [asacol, lialda, pentasa], olsalazine [dipentum],

sulfasalazine [azulfidine]);
▪ Immune system suppressors (e.g., azathioprine [azasan, imuran], mercaptopurine [purinethol],
cyclosporine [gengraf, neoral]); monoclonal antibody form of antitumor necrosis factor (e.g.,
infliximab [remicade]); nicotine patches may be used for short-term exacerbations

Surgical treatment

Surgical is indicated for the client with ulcerative colitis intractable to medical management or to
treat complications such as perforation, haemorrhage, obstruction or toxic mega colon.

Types of surgery include

▪ Proctocolectomy with permanent or continent ileostomy

▪ Total colectomy with ileorectal anastomosis
▪ Total colectomy with ileoanal reservoir
Psychotherapy
▪ Psychotherapy can be a key component in the stepped-care approach to the treatment of IBS
and other functional GI disorders. Multiple different models of psychotherapy have been
used. These include short-term, dynamically oriented, individual psychotherapy; supportive
psychotherapy; hypnotherapy; relaxation techniques; and cognitive therapy

Psychological support

▪ Ulcerative colitis can be a lifetime illness with periods of exacerbation and remission that
can disrupt the person’s life situation. Because emotions and stress have been known to play
a role in exacerbation of the illness, psychological support may help to decrease the
 frequency of these attacks by helping the individual to recognize the stressors that precipitate
exacerbations and identify more adaptive ways of coping. The person with ulcerative colitis
often feels a lack of control over his or her life. Psychological support may help the client
cope with feeling of insecurity dependency and depression. It is extremely important that the
individual express feeling of repressed or suppressed anger and hostility.

TREATMENT OF PSYCHOSOMATIC DISORDERS

A major role of psychiatrists and other physicians working with patients with psychosomatic
disorders is mobilizing the patient to change behaviour in ways that optimize the process of
healing. This may require a general change in lifestyle (e.g., taking vacations) or a more
specific behavioural change (e.g., giving up smoking).

Relaxation Therapy

Cognitive-behavioural therapy methods are increasingly used to help individuals better manage their
responses to stressful life events. These treatment methods are based on the notion that cognitive
appraisals about stressful events and the coping efforts related to these appraisals play a major role
in determining stress responding

Cognitive-behavioral therapy approaches to stress management have three major aims:

▪ To help individuals become more aware of their own cognitive appraisals of stressful events
▪ To educate individuals about how their appraisals of stressful events can influence negative
emotional and behavioral responses and to help them reconceptualize their abilities to alter
these appraisals
▪ To teach individuals how to develop and maintain the use of a variety of effective cognitive
and behavioral stress management skills.

Stress-Management Training

Five skills form the core of almost all stress-management programs: self-observation, cognitive
restructuring, relaxation training, time management, and problem-solving.

SELF-OBSERVATION:
A daily diary format is used, with patients being asked to keep a record of how they responded to
challenging or stressful events that occurred each day. A particular stress (e.g., argument with
spouse) may precipitate a sign or symptom (e.g., pain in the neck).

COGNITIVE RESTRUCTURING:

This helps participants become aware of, and change, their maladaptive thoughts, beliefs, and
expectations. Patients are taught to substitute negative assumptions with positive assumptions

RELAXATION TRAINING:

Edmund Jacobson in 1938 developed a method called progressive muscle relaxation to teach
relaxation without using instrumentation as is used in biofeedback. Patients were taught to relax
muscle groups, such as those involved in "tension headaches." When they encountered, and were
aware of, situations that caused tension in their muscles, the patients were trained to relax. This
method is a type of systematic desensitization-a type of behavior therapy.

Hypnosis

Hypnosis is effective in smoking cessation and dietary change augmentation. It is used in

combination with aversive imagery (e.g., cigarettes taste obnoxious). Some patients exhibit a
moderately high relapse rate and may require repeated programs of hypnotic therapy (usually three
to four sessions)

Biofeedback

Neal Miller in 1969 published his pioneering paper "Leaming of Visceral and Glandular
Responses," in which he reported that, in animals, various visceral responses regulated by the
involuntary autonomic nervous system could be modified by learning operant conditioning carried
out in the laboratory. This led to humans being able to learn to control certain involuntary
physiological responses (called biofeedback) such as blood vessel vasoconstriction, cardiac rhythm,
and heart rate. These physiological changes seem to play a significant role in the development and
treatment or cure of certain psychosomatic disorders
TIME MANAGEMENT

Time-management methods are designed to help individuals restore a sense of balance to their lives.
The first step in training in time-management skills is designed to enhance awareness of current
patterns of time use. To accomplish this goal, individuals might be asked to keep a record of how
they spend their time each day, noting the amount of time spent in important categories, such as
work, family, exercise, or leisure activities.

Alternatively, they may be asked to list the important areas in their lives and then asked to provide
two time estimates: (1) the amount of time they currently spend engaging in these activities and (2)
the amount of time they would like to spend engaging in these activities. Frequently, a substantial
difference is seen in the time individuals would like to spend on important activities and the amount
of time they actually spend on such activities. With awareness of this difference comes increased
motivation to make changes

PROBLEM-SOLVING

The final step is problem-solving, in which patients try to apply the best solution to the problem
situation and then review their progress with the therapist

TREATMENT AND NURSING MANAGEMENT:

Nursing assessment

Client Assessment Data Base:

Hypertension:

Activity /Rest

▪ Fatigue , sleep disturbance

Circulation

▪ Chronic high blood pressure with no organic origin

▪ Dizziness, nervousness, palpitation

Ego integrity
 ▪ May report emotional trauma, presence of stressful situations in daily life ; controlled
emotionally
▪ Increased areas in urban areas rather than in rural or topical areas (reflects more relaxed
lifestyle’s)

Food/Fluid

▪ Obesity , sensitivity to salt

Migraine / Headache:

Activity /Rest

▪ Fatigue

Food /Fluid

▪ Nausea ,vomiting

Neurosensory

▪ Sensitivity to light /noise ; visual disturbances; sensory/ motor disturbances (e.g.:

tingling of faces, hands; staggering gait)

Mental status

▪ Compulsive / perfectionistic, conscientious, intelligent, neat , inflexible, rigid ,resentful;

experiences guilt feelings

Pain/Discomfort

▪ Headache pain, unilateral or bilateral; aching, throbbing

Associated symptoms: nausea /vomiting photosensivty

Other symptoms /conditions that may be noted:

▪ Genitourinary: Menstrual and urinary disturbances; dyspareunia , impotence’s

▪ Musculoskeletal: Joint stiffness/ pain, backaches, muscle cramps ,tension headache
 ▪ Skin : Pruritus, cutaneous inflammation( neurodermitits),excessive sweating (hyperhidrosis )
▪ Others: Autoimmune diseases, manifested as Rheumatoid arthritis, systemic lupus of
erythematous, myasthenia gravis, and pernicious anemia, etc.

NURSING DIAGNOSIS

Nursing diagnosis are formulated from the data gathered during the assessment phase and with
background knowledge regarding predisposing factors to the disorders. Knowledge regarding
predisposing factors to the disorders. Knowledge regarding predisposing factors to the disorders. Some
common nursing diagnosis for clients with specific psychophysiological disorders include:

▪ Ineffective coping related to repressed anxiety and inadequate coping methods

▪ Deficient knowledge related to psychological factors affecting medical conditions.
▪ Low self-esteem related to unmet dependency needs
▪ Ineffective role performance related to physical illness accompanied by real or perceived
disabling symptoms.

CONCLUSION:
Medical Conditions Due To Psychological Factors could be very confusing and difficult to diagnose
and therefore could hamper the care needed and provided to the patient. In order for the health care
provider and team to make the diagnosis, either the factors must have influenced the course of the
medical condition, interfered with its regarding treatment, contributed to health risks, or
physiologically aggravated the medical condition. It is the responsibility of a psychiatric nurse to
have a sound knowledge in assessing and identified the illness in order to provide a complete
holistic and unbiased care to the patient.

JOURNAL REFERANCE

Relationship between Stress and Psychosomatic Complaints among Nurses in Tabarjal Hospital

ABSTRACT
This research was conducted to examine the relationship between stress and psychosomatic
complaints among nurses in Tabarjal hospital. To achieve this aim, the researcher used the
descriptive method and selected a sample consisting of (56) nurses working in hospital through the
simple random sampling technique. The respondents were requested to complete a questionnaire for
rating of stress and the most common psychosomatic diseases. The collected data were analyzed
statistically by using SPSS. The results revealed that the stress was dominant among nurses in
Tabarjal hospital, the prevalence of psychosomatic complaints was significantly higher in nurses,
and there was significant correlation between stress and psychosomatic complaints among nurses.
Conclusion: This research confirmed the effect of strains on the prevalence of psychosomatic
symptoms among nurses in Tabarjal hospital. Further, implications of the results were discussed on
the light of some related researches.

Is there a causal relationship between stress and migraine? Current evidence and implications
for management

Background: The purpose of this narrative review is to examine the literature investigating a causal
relationship between stress and migraine and evaluate its implications for managing migraine.

Methods: PubMed, PsycINFO and CINAHL were searched from 1988 to August 2021, identifying
2223 records evaluating the relationship between stress and migraine. Records were systematically
screened. All potentially relevant records were thematically categorized into six mechanistic groups.
Within each group the most recent reports providing new insights were cited.

Results: First, studies have demonstrated an association of uncertain causality between high stress
loads from stressful life events, daily hassles or other sources, and the incidence of new-onset
migraine. Second, major stressful life events seem to precede the transformation from episodic to
chronic migraine. Third, there is some evidence for changes in levels of stress as a risk factor for
migraine attacks. Research also suggests there may be a reversed causality or that stress-trigger
patterns are too individually heterogeneous for any generalized causality. Fourth, migraine symptom
burden seems to increase in a setting of stress, partially driven by psychiatric comorbidity. Fifth,
stress may induce sensitization and altered cortical excitability, partially explaining attack
triggering, development of chronic migraine, and increased symptom burden including interictal
symptom burden such as allodynia, photophobia or anxiety. Finally, behavioral interventions and
forecasting models including stress variables seem to be useful in managing migraine.
Conclusion: The exact causal relationships in which stress causes incidence, chronification,
migraine attacks, or increased burden of migraine remains unclear. Several individuals benefit from
stress-oriented therapies, and such therapies should be offered as an adjuvant to conventional
treatment and to those with a preference. Further understanding the relationship between stress,
migraine and effective therapeutic options is likely to be improved by characterizing individual
patterns of stress and migraine, and may in turn improve therapeutics.

REFERENCE
Book reference:
• Kaplan & Sadock’s. Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. 11th Ed.
Wolters Kluwer South Asian edition.477-89.
• Psychiatry, Fourth Edition Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B.
First, Michelle B. Riba 2015.2401-22.
• Ahuja N. A short textbook of psychiatry. 7thedition.New Delhi: Jay Pee brothers medical
publishers ; 2011.147-50.
• Psychiatry, Fourth Edition Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B.
First, Michelle B. Riba 2015.2399-47.
• Stuart WG. Principles and practices of psychiatric nursing. 9th ed. St. Louis Missouri: Mosby
Publishers; (2009).
• Videbeck. L. S. Psychiatric Mental health Nursing. 4th Ed. Lipincott F.A. Davis and
company publications. 2010
Journal references:

• Abdelrahim I Humaida I Relationship between Stress and Psychosomatic Complaints among

Nurses in Tabarjal Hospital Open Journal of Medical Psychology, 2012; 6(1) : 15-19
• Stubberud A, Buse DC, Kristoffersen ES, Linde M, Tronvik E. Is there a causal relationship
between stress and migraine? Current evidence and implications for management. J
Headache Pain. 2021 20;22(1):155.
• Heine H, Weiss M. Life stress and hypertension. Eur Heart J. 1987( 8):45-55.
Net references:
• Boone JL. Stress and hypertension. Prim Care. 1991 Sep;18(3):623-49.
• European Society for Medical Oncology Psycho-oncology and cancer: linking psychosocial
factors with cancer development. B. Garssen
• Nakaya N . Effect of Psychosocial Factors on rheumatoid arthritis Risk and Survival J
Epidemiol. 2014; 24(1): 1–6.
• Wolman B.B.,(1988).Psychosomatic-psychophysiological disorders Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840908/.