Psychosomatic medicine by Vriddhi


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									Dr Savitha
 Folk wisdom of many cultures suggest that people
 under psychological stress are likely to become ill

 In the past few decades, medical research has provided
 compelling evidence of this psyche (mind) and soma
 (body) relationship
 Stressed people are more likely to become ill

 Medical illnesses or their treatments can themselves
 lead to or exacerbate psychological symptoms

 The psychological symptom displayed by a patient can
 sometimes be the first indication of a serious medical
    Psychological factors affecting
         medical conditions
 Acc to DSM-IV-TR:

 Psychiatric illnesses such as depression, anxiety,

 Poor health behaviors such as smoking, sedentary
  lifestyle, unhealthy diet, alcohol use
 Stress related physiological responses ( increased
  sympathetic system activity, increased release of

 Maladaptive personality traits (OCPD, Type A
  personality, hostile)

 Coping styles (inability to express feelings, regression)
Depression and medical illness
 Variety of physical changes having medical

 Risk of death after MI high in depressed patients

 More likely to develop DM, stroke, osteoporosis
 Forces that are brought against an object in
  equilibrium (physics)

 Life events or stressors that have the force to alter the
  expected course of an individual’s goals, employment,
  relationships, health (psychiatry)
           Stressful life events
 Some events : extreme psychological stressors

 Even ordinary life events cause stress

 Schemes to quantify stress

 Holmes & Rahe – social readjustment scale ( LE’s have
 positions in a hierarchy, determined by power to cause
 a person to alter or readjust his life)
 Positive life events can also be stressful

 The more life adjustments patients have to make, the
  higher their risk for medical and psychiatric illnesses
  Effects of stress on physiological
 General adaptation syndrome: Hans Selye

 Homeostatic mechanisms that the body uses in
 response to social stress

 Neuroendocrine responses

 Immediate effect: release of catecholamines
 Exacerbate cardiovascular disorders (CCF,
  arrhythmias, HT)

 Pain disorders such as migraine

 Later effect: increased release of cortisol

 Altered immune function, reduced resistance to
  infection, cancer
Stress & immune system function
 Psychoneuroimmunology (PNI)

 External stress stimulates hypothalamus --- release of
 CRF---- rapid release of ACTH ---- release of cortisol

 Measures of alterations in immune responses:
 decreased lymphocyte response to mitogens and
 antigens, impaired function of NK cells
Medical students show
reduced NK cell cytotoxicity
and decreased cell mediated
immunity during exams !!!
   Use of stress reduction to treat
           physical illness
 Patients can improve the outcome of their illnesses if
  they successfully reduce their life stress

 Pt is responsible if his illness worsens -----
  disappointment, guilt, depression if stress reduction
  strategy fails

 Evidence exists both for and against this notion
     Medical conditions associated with
         psychological symptoms
 Social problems caused by medical illnesses often
  result in psychological difficulties

 Common complaints include depression, anxiety and
  disorientation (delirium)

 Talk to patient, help to organise and activate his or her
  social support system
 Antianxiety agents and anti depressants

 For severe psychiatric symptoms: consultation liaison

 Patient populations more prone for stress are:
 hospitalised, especially surgical pt s, treated in ICU or
 CCU, HIV, renal dialysis, pt s with chronic pain
Surgical patients
 Stressful for everyone

 Increased risk fro those who believe they will not
 survive surgery and those who do not admit they are
 worried before surgery

 Doc must encourage them to talk about their fears and
 address them honestly

 Education beforehand improves outcome
Renal dialysis
 Increased risk for depression

 Recognition that they are dependent life long on
 others and machines

 Good communication, use of in home dialysis units
 reduces stress
 Delirium or “ICU psychosis”

 Enhance social and sensory input by encouraging pt to
 talk, having visitors, providing orienting
 environmental cues

 Also pt to maintain as much control as possible over
 his or her envt
 Particular combination of psychological stressors

 Fatal illness, guilt at having contracted it, fear of
  spreading it to others

 Complex, painful, often costly treatment regimes

 If addicted to substance, must undergo the discomfort
  of withdrawal
 Homosexual pt s may be burdened further by need to
 reveal their sexual orientation to others

 Medical & psychological counseling

 Peers support groups

 Reassurance from physician

 Psychoactive meds for specific symptoms
     Patients with chronic pain
 Chronic pain is defined as pain lasting atleast 6
  months (DSM-IV-TR)

 Commonly reported by patients

 Associated primarily with physical factors but
  influenced by psychosocial factors
 Ability to tolerate pain reduced by depression, anxiety,
  life stress, physical or sexual abuse

 Religious, cultural, ethnic factors influence pain
  expression, response to pain

 Certain cultures encourage expression, others see
  value in remaining stoic
Treating pain
 Pain relief has physiological and psychological

 People who experience pain after a medical or surgical
 procedure have a higher risk of morbidity and slower
 recovery from the procedure

 Use of analgesics (eg opioids) , nerve blocking surgical
 Implants that provide electrical stimulation of large
  diameter afferent nerves , which may block pain perception
  ( gate control theory)

 Antidepressant and anti seizure medication

 The fear that pt s will become addicted to narcotics is

 Most pt s at higher risk for depression than opioid
Administration of pain medication
 Schedule and route of administration important

 Scheduled administration may be more effective than
 administration on demand

 Infants and children should also receive anesthesia
 and analgesia

 Use of oral medications (lollipop), transdermally (skin
Placebo effects
 Placebo response is defined as a subjective
 responsiveness to an inactive pharmacologic agent

 The mechanism by which cognitive cues can activate
 the placebo effect is not well understood

 It apparently involves “real” changes in neural function
 (eg release of endogenous opioids )
 Imaging shows that placebo activates brain regions
  with high concentrations of opioid receptors (brain
  stem) , similar to opioid analgesics

 It is unethical to give a pt placebo without first
  notifying him that he may be receiving either a
  placebo or active drug
Other treatments
 Serotonin & glutamate involved in pain experience

 Antidep s and anti epileptic drugs useful in pain

 TCA’s, SNRI’s : arthritis, facial pain, headache, IBS
 Act in 2 ways:

 Directly stimulate efferent inhibitory pain pathways
 Decrease pain indirectly by improving symptoms of

 NMDA receptor modulators (gabapentin) effective in
 pain relief, especially when it results from injury to
 CNS or peripheral nervous system

 Biofeedback, hypnosis, meditation

 Relaxation training

 These pt s need less pain meds, become more active,
 return quickly to pre pain lifestyles
   Other psychosomatic relationships
 Medical conditions presenting with psychological

 Depression, anxiety, psychosis, personality changes
 can be signs of medical illnesses

 Neurological problems like dementia, toxic states,
 neoplasms (particularly GI cancers), rheumatologic
 illnesses, connective tissue disorders
 A first episode of depression,
 anxiety or especially psychosis in
 persons older than 50 years should
 occasion an aggressive medical
 work up before assuming that the
 disorder is primarily psychiatric
 Anemia, arrhythmia, chronic infections with fever

 Cushing’s disease, hyperthyroidism, hypoglycemia

 Phaeochromocytoma, pulmonary disease, severe
 blood loss
 AIDS, brain lesions, chronic pain

 Addison’s disease, Cushing’s disease, hypothyroidism

 Multiple sclerosis, Parkinson’s disease

 Vitamin deficiencies
Personality changes
 Brain infections & neoplasms

 Dementia

 Huntington’s disease, temporal lobe epilepsy

 Wilson’s disease
Mania or psychotic symptoms
 AIDS, acute intermittent porphyria

 Cushing’s disease, multiple sclerosis

      Medication induced psychological
 Psychotropic medications can also cause psychiatric

 Antipsychotics, antidepressants and stimulants can
  produce agitation, anxiety, insomnia and even psychotic

 Sedation, problems with concentration, sexual dysfunction

 Non psychotropic agents can also produce psychiatric
 Analgesics--- psychotic symptoms

 Anti arrhythmics---- confusion and delirium

 Antiasthmatic ---- confusion, anxiety

 Antibiotics ----- psychotic symptoms, depression,
 Anticholinergics ---- agitation, delirium

 Anticonvulsants ---- mood symptoms, confusion

 Antihistamines ---- sleepiness

 Antihypertensives ---- depression, sexual dysfunction
 Antineoplastics --- confusion, mood changes

 Antiparkinson agents ---- anxiety, psychosis

 Cardiac glycosides --- depression, fatigue

 Calcium channel blockers ----- depression
 Hypoglycemics ---- anxiety, confusion

 NSAID’s ---- euphoria, anxiety

 Peptic ulcer drugs ---- depression, psychotic symptoms

 Steroid hormones ---- aggressiveness, euphoria,
 confusion, pseudotumor cerebri ( corticosteroids
Thank you

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