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

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. 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. 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. It emphasizes the unity of mind and body and the interaction between them. A holistic approach to medicine. A holistic approach to medicine.

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 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.

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. 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. Psychosomatic concepts have contributed greatly to those approaches of medical care.

Biomedical Model: Biomedical Model: The application of biological science to maintain health and treating disease. The application of biological science to maintain health and treating disease. Engel (1977) proposed a major change in our fundamental model of health care. 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. The new model continues the emphasis on biological knowledge, but also encompasses the utilization of psychosocial knowledge. “Biopsychosocial Model”

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. 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. 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.

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.

Neurotransmitter Responses to Stress Stressors activate noradrenergic systems in the brain and cause release of catecholamines from the autonomic nervous system. 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. Stressors also activate serotonergic systems in the brain, as evidenced by increased serotonin turnover. Stress also increases dopaminergic neurotransmission in mesoprefrontal pathways. Stress also increases dopaminergic neurotransmission in mesoprefrontal pathways.

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.

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.

High level of Cortisol results in suppression of immunity which can cause susceptibility to infections and possibly also in many types of cancer. 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. Changes in the immune system in response to stress are now very well established.

Immune suppression in response to stress occurs even after removal of the adrenal gland !!. 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. There appears to be an alternative path, other than through the adrenals, for the brain to influence the immune response.Psychoneuroimmunology

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.

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)

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

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-adrenal (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).

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

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 patient’s conscious control.

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

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.

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.

HYPOCHONDRIASIS Preoccupation with the fear of developing a serious disease or the belief that one has a serious disease. 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. 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.

PAIN DISORDER Preoccupation with pain is consuming and to some extent disabling. 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. 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. Psychological factors are judged to play a role in this disorder.

BODY DYSMORPHIC DISORDER Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. 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. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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

Consultation Liaison Psychiatry The subspecialty of psychiatry that incorporates clinical service, teaching, and research at the borderland of psychiatry and medicine. 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. Liaison refers to interactions with nonpsychiatrist physicians for teaching psychosocial aspects of medical care.

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 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 CL psychiatrist MUST have knowledge of psychotherapeutic and psychopharmacological interventions

Consultation vs. consultation-Liaison Liaison model is based on an early detection strategy to identify potential problems. 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. 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 patient’s illness. Education of nonpsychiatric physicians and health professionals about medical and psychiatric issues related to a patient’s 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. Liaison services lead to heightened sensitivity by medical staff, which result in earlier detection and more cost-effective management of patients with psychiatric problems.

MEDICAL ILLNESS PSYCHIATRIC ILLNESS MEDICAL ILLNESS PSYCHIATRIC ILLNESS MODELS OF COMORBIDITY

TREATMENT FOR MEDICAL ILLNESS PSYCHIATRIC ILLNESS TREATMENT FOR PSYCHIATRIC ILLNESS MEDICAL ILLNESS PSYCHIATRIC ILLNESS MEDICAL ILLNESS SMOKING AND NICOTINE DEPENDENCE