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

2. relation 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. Unity of mind and body Integrates mind and body into a psychobiological unit; as dynamic interacting systems. A holistic approach to medicine.

3. Implications: Unity of mind and body: 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 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. 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. 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.

9. 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. 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. 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., 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, 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- psychobiological research is to delineate the mechanisms by which experiences cause certain types of physiological reactions that result in disease states.

16. Psychological factors have been closely studied as part of the pathogenesis of the condition. Relatively strong evidence indicates that some persons have greater blood pressure reactivity than do others. Various behavioral procedures including biofeedback, relaxation training, and psychotherapy have been used as interventions.

17. Recent studies have shown that personality features of hostility, irritability, hypersensitivity, and impaired coping ability correlate significantly with serum pepsinogen concentration in peptic ulcer disease patients. Irritable Bowel Syndrome is the most frequently documented gastroenterological syndrome that has been related to psychiatric influences. There is a strong & consistent association between functional gastrointestinal disorders and psychological factors.

18. 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.

19. Somatization disorder Conversion disorder Pain disorder Hypochondriasis Body Dysmorphic Disorder

20. 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. 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. 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. 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. 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. 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. 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. 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. participate in ward rounds and team meetings Liaison psychiatrist may participate in ward rounds and team meetings while addressing the behavioral issues. Education Education of nonpsychiatric physicians and health professionals about medical and psychiatric issues related to a patient’s illness. heightened sensitivity earlier detection cost-effective 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. MEDICAL ILLNESS PSYCHIATRIC ILLNESS MEDICAL ILLNESS PSYCHIATRIC ILLNESS MODELS OF COMORBIDITY

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