Psychosomatic Medicine Aws Khasawneh, MD.

Overview: * 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.

Stress theory: Definitions Stress: a state of disturbed equilibrium Stressor: the life events that do the disturbance Stress response: the physiological and psychological responses that seek to diminish the impact of stressor and restore equilibrium/ homeostasis.

Types of Stressors Environmental Physiological Emotional (psycho-social)

Measuring Stress Stress can be measured in three different ways: ◦ Paper-and-pencil scales ◦ Interviews ◦ Physiological measurements

Social Readjustment Rating Scale (SRRS) The Social Readjustment Rating Scale (SRRS) was developed in 1967 by Thomas Holmes and Richard Rahe. In many ways, their work was influenced by earlier work by Adolph Meyer.

Adolph Meyer ( ) In the 1930s, Meyer proposed that life events were related to health ◦ These events need not be negative, bizarre, or catastrophic; they must simply be interpreted as important life changes, requiring some degree of coping  e.g., marriage, moving to new city, changing jobs, death in family ◦ Although he noted the effects these life changes had on patients with diseases, he did not document his findings with empirical research

Thomas Holmes and Richard Rahe constructed a social readjustment rating scale and asked hundreds of people to rank the relative degree of adjustment required by changing life events. Holmes and Rahe listed 43 life events associated with varying amounts of disruption and stress in average people’s lives

Events with high scores require people to make the most social readjustment in their lives. The need for social readjustment is directly correlated with increased risk of medical and psychiatric illness. Score of 300+( in a given year): At high risk of illness.80% Score of : Risk of illness is moderate (reduced by 30% from the above risk). Score <150: Only have a slight risk of illness.

Life Change Units and Disease Holmes and Rahe 1967

RESPONSE TO STRESS The response to any stressor by individual is buffered by: 1. the accuracy of the appraisal 2. adequacy of resources and social support 3. maturity of coping behavior

THE STRESS MODEL Two major facets of stress response. 1-“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.

15Comer, Abnormal Psychology, 7e 2-The hypothalamus, pituitary gland, the adrenal cortex mediate the second facet.

Neurotransmitter Responses to Stress noradrenergic -Stressors activate noradrenergic systems in the brain and cause release of catecholamines from the autonomic nervous system. serotonergic -Stressors also activate serotonergic systems in the brain, as evidenced by increased serotonin turnover. dopaminergic -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. Changes in the immune system in response to stress are now very well established.

Psychological factors adversely affect the general medical condition in one of the following ways:  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. Ex: Psychological symptoms affecting medical condition (e.g., depressive symptoms delaying recovery from surgery; anxiety exacerbating asthma). : Maladaptive Personality traits or coping style e.g. hostile, pressured behavior contributing to cardiovascular disease, type A personality) (2) the factors interfere with the treatment of the general medical condition. Ex : pathological denial of the need for surgery in a patient with cancer,

(3) the factors constitute additional health risks for the individual. Ex: Maladaptive health behaviors:  Tobacco  Poor diet/ lack of exercise  Excess Alcohol  Risky Sexual Behavior  Homicides & Physical Abuse  Unintentional Injuries (4) stress-related physiological responses precipitate or exacerbate symptoms of a general medical condition. Ex: stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache

Other relationships Medical conditions that can present with psychiatric symptoms. Ex: neurological illnesses, neoplasm, endocrine disturbances and viral illnesses can present with depression Psychotropic and non-psychotropic medications can produce psychiatric symptoms. Ex: antihistamine, steroids, antiparkinson, antihypertensive, analgesics…etc

Psychological stress in hospitalized patients Psychological problems are common among hospitalized patients. Usually these problems have a negative impact on the patient’s physical problem Treating physician should manage to handle these problem utilizing the social support system, and psychotropic medications. In sever psychiatric problem CL Psychiatrists have to be involved in management.

Examples of psychiatric problems in hospitalized patients: Delirium: disorientation, anxiety, sleep disturbance, psychotic symptoms. Elderly patient are at grater risk, patients undergo cardiac or orthopedic surgery, those being treated in ICU or CCU. And renal dialysis patients. Surgical patients: those who believe that they won’t survive surgery and those who do not admit that they are worried before surgery, are at greatest psychological and medical risk

Patients with chronic pain Chronic pain: pain lasting at least 6 months. It’s associated with physical factors, psychological factors or both. Psychological factors such as depression, anxiety, physical and sexual abuse can decrease tolerance to pain/ decrease pain threshold. Chronic pain results in depression.

Treating pain Analgesics: specially in pain induced by physical illness, patient controlled analgesia, nerve block procedures. Antidepressants: TCA, SSRI, specially in patient with arthritis, facial pain and headache. Mechanism 1-direct stimulation of inhibitory pain pathway 2- indirect by improving depression symptoms. Behavioral, cognitive psychotherapy: biofeedback, hypnosis, meditation and relaxation training

Psychological stressors in AIDS patients Having a fatal illness Guilt feelings about how they got infected (multiple sex partners, IV drug use) Guilt feelings about possibly infecting other. Being met with fear of contagion from medical staff, family and friends. Homosexual patients may compelled to come out to others. Depression is the most common psychiatric diagnosis in HIV +ve patients.