IzBen C. Williams, MD, MPH Instructor

Lecture # 14a PSYCHOSOMATIC MEDICINE

Stress Responses Exposure to emotional and physical stress leads to a variety of responses. These responses are adaptive in the short run, but can lead to pathology if stress is prolonged/protracted, or of dysregulation of our system occurs The two major components of the stress response system are: 1) Autonomic nervous system, and 2) Hypothalamic-pituitary-adrenal (HPA) axis

Stress Responses 1) Autonomic nervous system: STRESS » activation of the locus ceruleus and diffuse release of Norepinephrine (NE)in the brain The result is arousal, vigilance, and anxiety. NE also stimulates the dopaminergic system (enhancing cognitive function) and the amygdala and hippocampus (enhancing memory retrieval). The sympathetic nervous system stimulates adaptive peripheral responses to stress (eg. tachycardia)

Stress Responses 2) HPA axis: Secretion of corticotropin-releasing hormone (CHR), which is stimulated by stress, heightens arousal and inhibits feeding and sexual arousal. Prolonged stress inhibits growth hormone (GH) secretion and immune function probably through the HPA axis.

Stress Responses The adaptive value of the stress response is evident, but when stress is unremitting the system can malfunction leading to many disorders: Emotional Mental Psychosomatic

I - Stress and Health A. Psychological factors affecting health. Psychological factors may initiate or exacerbate symptoms of mental disorders involving almost any body system (psychosomatic symptoms). These factors include 1. Poor health behavior (smoking, failure to exercise) 2. Maladaptive personality style (eg, type A personality) 3. Chronic or acute life stress (due to, for eg., emotional, social, economic problems)

I - Stress and Health B. Mechanisms of physiologic effects of stress 1. Acute or chronic life stress leads to activation of the autonomic nervous system, which in turn affects cardiovascular and respiratory systems 2. Stress also leads to altered levels of neurotransmitters (eg serotonin, NE) which leads to changes in mood and behavior 3. Stress can increase the release of ACTH which leads to the release of cortisol, ultimately resulting in depression of the immune system as measured by decreased lymphocyte response to mitogens and antigens, and impaired function of the natural killer cells.

I - Stress and Health C. Stressful life events. High levels of stress in a patient’s life may be related to an increased likelihood of medical and psychiatric illness 1. The social Readjustment Rating Scale of Holmes and Rahe (which also includes positive events like holidays) ranks the effects of life events. Events with the highest scores require people to make the most social readjustment in their lives 2. The need for social readjustment is directly correlated with increased risk of medical and psychiatric illness; in studies by Holmes and Rahe, 80% of patients with a score of 300 points in a given year became ill during the next year

I - Stress and Health D. Other psychosomatic relationships 1. Medical conditions that can present with psychiatric symptoms such as depression, include neurological illnesses (eg., dementia), neoplasms (particularly pancreatic and other gastrointestinal cancers), endocrine disturbances (eg., hypothyroidism), and viral illnesses (eg., AIDS) 2. Non-psychotropic and psychotropic medication can produce psychiatric symptoms such as confusion (eg., anti-asthmatics), anxiety (eg., anti-parkinsonism agents), depression (eg., anti-hypertensives), sedation (eg. Antihistamines), agitation (eg., steroid hormones), and even psychotic symptoms (eg., analgesics, antibiotics, antihistamines

II – Psychological Stress in Hospitalized Patients A. Overview 1. Not uncommonly, medical and surgical patients have concurrent psychological problems. These problems cause psychological stress, which can exacerbate the patient’s physical disorder 2. Usually, the treating physician handles these problems by helping to organize the patient’s social support system and by using specific psychotropic medications 3. For severe psychiatric problems (eg., psychotic symptoms) in hospitalized patients, consultation- liaison psychiatrists may be needed.

II – Psychological Stress in Hospitalized Patients B. Problems of hospitalized patients 1. Common psychological complaints in hospitalized patients include anxiety, sleep disorders, and disorientation, often as a result of delirium. 2. Patients who are at greatest risk for such problems include those undergoing surgery, or renal dialysis, or those being treated in the intensive care unit (ICU) or coronary care unit (CCU)

II – Psychological Stress in Hospitalized Patients C. Surgical patients 1. Patients undergoing surgery who are at greatest psychological and medical risk are those who believe that they will not survive surgery as well as those who do not admit that they are worried before surgery. 2. To reduce risk, the doctor should encourage patients to take a positive attitude and talk about their fears. The doctor should also explain to patients what they should expect during and after the procedure (eg., mechanical support, pain)

II – Psychological Stress in Hospitalized Patients D. Patients undergoing renal dialysis 1. Patients on renal dialysis are at increased risk for psychological problems (eg., depression, suicide, and sexual dysfunction) in part because their lives depend on other people and on machines 2. Psychological and medical risk can be reduced through the use of in-home dialysis units, which cause less disruption in the patient’s life.

II – Psychological Stress in Hospitalized Patients E. ICU or CCU Patients 1. Patients treated in ICU or CCU are at increased risk for depression and delirium (ICU psychosis). 2. Because these patients have life-threatening illnesses, their clinical stability is particularly vulnerable to psychological symptoms. 3. Psychological and medical risk can be reduced by enhancing sensory and social input (eg., placing the patient’s bed near a window, encouraging him or her to talk), and allowing the patient to control the environment (eg., lighting, pain medication) as much as possible

III – Patients with Chronic Pain A. Psychosocial factors 1. Chronic pain (lasting at least 6 months) is a commonly encountered complaint of patients. It may be associated with physical factors, psychological factors or a combination of both. a. Decreased tolerance for pain is associated with depression, anxiety, and life stress in adulthood and physical and sexual abuse in childhood b. Pain tolerance can be increased through biofeedback, physical therapy, hypnosis, psychotherapy, meditation, and relaxation training

III – Patients with Chronic Pain A. Psychosocial factors 2. Depression may predispose a person to develop chronic pain. More commonly, chronic pain results in depression 3. People who develop pain after a procedure have a higher risk of morbidity and mortality and a slower recovery from the procedure 4. Religious cultural and ethnic factors may influence the patient’s support system to the pain 5. Psychological “benefits” (secondary gain) of chronic pain include attention from others, financial gain, and justification of inability to establish social relationships.

III – Patients with Chronic Pain B. Treating pain 1. Relief of pain caused by physical illness is best achieved by analgesics (eg., opioids), using patient-controlled analgesia, or nerve-blocking surgical procedures 2. Antidepressants, particularly heterocyclics, are useful in the management of pain. a. Antidepressants are most useful for patients with arthritis, facial pain, and headache b. Their analgesic effect may be the result of stimulation of efferent inhibitory pain pathways c. Although they have direct analgesic effect they also may decrease pain directly by improving symptoms of depression

III – Patients with Chronic Pain B. Treating pain 3. According to the gate control theory, the perception of pain can be blocked by electric stimulation of large diameter afferent nerves. Some patients are helped by this treatment 4. Patients with pain caused by physical illness also benefit from behavioral, cognitive, and other psychological therapies, by needing less pain medication, becoming more active, and showing increased attempts to return to normal lifestyle

III – Patients with Chronic Pain B. Treating pain 5. The goal of chronic pain management should be to minimize narcotic medication and maximize function. 6. The patient with chronic pain may frustrate the physician to the extent that mutual intolerance develops and inadequate treatment is provided. 7. Compassionate management demands that the patient’s pain and suffering be considered genuine, even if there appears to be significant psychological overlay

III – Patients with Chronic Pain C. Programs for pain treatment 1. Scheduled administration of analgesics before the patient requests it (eg., every three hours) is more effective than medication administered when the patient requests it (on demand). Scheduled administration separates the experience of pain from the receipt of medication. 2. Many patients with chronic pain are under- medicated because the physician fears that the patient will become addicted to opioids. However recent evidence shows that patients with chronic pain easily discontinue the use of opioids as the pain remits 3. Pain pts. are more at risk for depression than for addiction.

III – Patients with Chronic Pain D. Pain in children 1. Children feel pain, and remember pain as much as adults do. 2. Because children are afraid of injections, the most useful ways to administer pain medication to them is orally, trans-dermally, or in older children and adolescents, via PCA

IV – Patients with AIDS A. Psychological stressors. AIDS and HIV-positive patients (a prototype) must deal with particular psychological stressors not seen together in other infectious disorders 1. These stressors include having a fatal illness, feeling guilt about how they contracted the illness and about possibly infecting others, and being met with fear of contagion from medical personnel, family, and friend. 2. HIV-positive homosexual patients may be compelled to “come out”. 3. Depression is commonly seen in AIDS patients 4. Medical and psychological counseling can reduce medical and psychological risks in HIV positive pts.

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