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PSYCHOSOMATIC MEDICINE

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Title: PSYCHOSOMATIC MEDICINE


1
PSYCHOSOMATIC MEDICINE
  • Dr. YASER ALHUTHAIL
  • Ass. Professor Consultant
  • Consultation Liaison Psychiatry

2
  • 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.

3
  • 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.

4
  • 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.

5
  • 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

6
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.

7
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.

8
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.

9
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.

10
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.

11
  • 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.

12
  • 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

13
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.

14
  • 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)

15
  • 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.

16
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).

17
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

18
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.

19
Somatoform Disorders
  • Somatization disorder
  • Conversion disorder
  • Pain disorder
  • Hypochondriasis
  • Body Dysmorphic Disorder

20
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.

21
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.

22
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.

23
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.

24
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.

25
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

26
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.

27
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

28
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.

29
MODELS OF COMORBIDITY
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
30
TREATMENT FOR MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
TREATMENT FOR PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
PSYCHIATRIC ILLNESS
MEDICAL ILLNESS
SMOKING AND NICOTINE DEPENDENCE
31
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