PSYCHOSOMATIC DISORDERS

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					PSYCHOSOMATIC
  DISORDERS
     By:Dr.Manju K.Xavier
    Ist MD Materia Medica,
        G.H.M.C Calicut
    Psychophysiological
disorders are once called as
 psychosomatic disorders.
Refer to a group of disorder
  in which conditions are
disturbed due to emotional
stress due to psychological
          factors.
It is an illness whose symptoms are caused by
mental process of the sufferer rather than
immediate physiological cause. If a medical
examination can find no physical or organic
cause, or if an illness appears to result from
emotional conditions such as anger anxiety,
depression or guilt, then it might be classified as
psychosomatic.However        in  some      illnesses
psychological factors seems to play a particularly
important part.They can influence not only the
cause of the illness but can also worsen the
symptom and can affect the course of the disorder.
Psychological factors are important in every
           illness.examples are
                          -duodenal ulcers
                   -irritable bowel syndrome
                         -bronchial asthma
                               -eczema
                              -psoriasis
                      -high blood pressure
                            -heart attacks
sometimes psychological factors can cause
 illhealth,without actually causing disease.
          Eg;anxiety,stress due to personal
problems leads to physical illness.eg;stress
                  headache.
    Psychosomatic symptoms show that a
human being can create physical symptoms
      that compensate for relation ship
deficiencies. (E.g. Hypnosis induced allergic
 reaction, indicates that a persons immune
 response can dramatically change during
  an intense mind body relationship.
 Mind can cause physical symptoms for example, when
  we are afraid or anxious we may develop a fast heart
rate, palpitations, feeling sick, shaking (tremor) sweating
 dry mouth, chest pain, headache, a knot in the stomach
                     and fast breathing.
  The physical symptoms are due to an overdrive of the
nervous impulse sent from the brain and to various parts
  of the body and to release of adrenaline into the blood
               stream when we are anxious.

There is also some evidence that the brain may be able
 to affect certain cells of the immune system, which is
          involved in certain physical diseases.
HISTORY OF THE CONCEPT
OF PSYCHOSOMATIC
ILLNESS
The term ‗psychosomatic ‗ is proposed as early as
1818.in 1935 dunbar published a book on ‗emotions and
body changes‘
                  The high incidence of psychosomatic
disorders among military personnel exposed to wartime
stresses during 2nd world war also contributes to the
concept of psychosomatic diseases.
      Examples of modern researches are
             -animal experiment of Pavlov on the
conditioned salivary reflex(1928)
             -cannon-1932-physiological    effect   of
intense emotional stimuli. He demonstrated that
stimulation of autonomic nervous system particularly
sympathetic nervous system.
              -1950-harold        wolff    observed
physiology of gastro intestinal tract appear to
correlate with the emotional state.hyper function
associated     with    hostility.and    hypofunction
associated with sadness.
The history of psychosomatic medicine dates to
ancient beliefs that the body can be affected by
external forces.
HOW DOES A PSYCHOSOMATIC
DISORDER OCCUR ?
Illness can be due to many factors.It can occur as a result of
social or environmental factors,genetic or hereditary factors etc. A
tendency for certain condition also run in
families. Some families also tend to suppress feelings.any
emotion tends to be expressed by physical symptoms.children
may learn this behavior which may continue to adult life.Some
people think that it is our personality that is a major factor in
determining which illness they develop. For example people with
what is known as type A personality tend to be ambitious,
impatient, and set themselves high standards.they seem more
likely to develop heart attacks.quet introverted individuals,who
tends to conceal their feelings and fears and to suppress
emotions, may be more likely to develop cancers.
      WHY DOES A
PSYCHOSOMATIC DISORDER
        OCCUR
Why the illness occurs at a particular time is
often a mystery.it could be that a
combination of the factors mentioned above
triggers off the illness.Should there be
untoward stress due to personal problems
at home or at work, or bereavement, then
an illness may result. We know for instance
that certain life events such as moving
house, getting divorced or suffering a
bereavement can precipitate physical
illnesses.Similarly, an existing illness may
worsen as a result of these stresses.
CLINICAL MANIFESTATIONS
• The commonly recognized psychosomatic
  conditions are clasifie according to the
  organ system involved are:-
• Gastro intestinal--peptic ulcer, ulcerative
  colitis, anorexia nervosa, irritable bowel
  syndrome
• Cardiovascular—essential hypertension,
  angina pectoris, myocardial infarction,
  cardiac neurosis, paroxysmal tachycardia
• .
• Respiratory – bronchial asthma,
  vasomotor rhinitis, and hay fever.
Urogenital – impotence, frigidity, menstrual
disorders, like ammenorrhoea, dysmenorrheal,
menorrhgia, metropathica haemorraghica, pre
menstrual tension.
Endocrine—hyperthyroidism (graves disease),
diabetes mellitus, obesity.
Skin –uriticaria, psoriasis, hyper hidrosis,
neurodermatitis, rosaceous
Musculoskeletal—rheumatoid arthritis, tension
headache.
Vasomotor –migraine.
•   Hyperacidity
•   ↓
•   Increased acid secretion
•   ↓
•   Inhibited dependence, general stress
         Hypertension
               ↓
       Vasoconstriction
               ↓
Conflict over hostility, general
            stress
•   Bronchial asthma
•   ↓
•   Bronchospasm
•   ↓
•   Conflict over wish for protection
•   or separation,
•   anxiety, general stress
           Migraine
               ↓
Vasoconstriction&vasodilation
               ↓
Conflict over control & general
            stress
•   Thyrotoxicosis
•   ↓
•   Increased TSH secretion
•   ↓
•   Conflict over premature self
    sufficiency
         Diarrhea
              ↓
Gastrointestinal cholinergic
         activation
              ↓
Conflict over an obligation
CLASSIFICATION
The revised fourth edition of ―Diagnostic and Statistical
Manual of Mental Disorders‖ (Dsm- Iv –TR) does not use
the term psychosomatic instead it describes the
psychological factors affecting the medical conditions as
―one or more psychological or behavioral problems that
adversely And significantly affect the course or outcome
of a general medical condition, or that significantly
increase a persons risk of an adverse outcome‖
                        Criteria in the tenth revision of
the ‗international classification of disease and related
health problems‖ ( ICD-10 ) are more general than the
DSM-IV-TR criteria.
According to the classification of ICD-10, the
psychosomatic disorders are described in chapter F-45.
According to the classification they can be divided into:-
             I. SOMATIZATION DISORDERS-
1) Multiple somatic symptoms in the absence of any
physical disorder.
2) The symptoms are recurrent and chronic
3) Symptoms are vague and narrated in dramatic
manner and involve multiple organs
4) Frequent change of treating doctor
5) presence of conversion symptom is common- it
should be differentiated from other physical complaints
like    multiple   sclerosis    ,hypothyroidism  ,hyper
thyroidism,SLE, pancreatic cancer and also from
psychiatric disorders like schizophrenia ,hypochondrias
is, conversion disorder ,delusion disorder etc.
             II HYPOCHONDRIASIS
persistent preoccupation with a fear or belief of
having one or more serious diseases based on
persons on interpretation of a normal body
function or a mionor physical abnormality. On
examination no physical abnormality found. Pre
occupation with medical terms is common.
Change of physician is also is common. Course is
usually chronic with remissions and relapses.
Ahge usually late third decade.
       III. SOMATOFORM AUTONOMIC
               DYSFUNCTION:-

           The symptoms are narrated as if they
were due to physical disorder of an organ system
that pre- dominantly under autonomic control.
For example – heart and CVS palpitation, upper
GIT ( aerophagy , hiccough ), lower GIT (
flatulence, IBS, ) respiratory system (
hyperventilation ), genitourinary system (
dysuria), other organ and systems.
IV.PERSISTENT SOMATOFORM PAIN DISORDER:-
                 TREATMENT            INVOLVED            FOR       A
PSYCHOSOMATIC DISORDER
                      Persistent, sivere and distressing pain is the
main feature which is either grossly in excess or inconsistent with
anatomical distribution of the nervous system. Pre occupation with
pain is common. More common with females and the onset is in
the third and fourth decades. The pain is not produced intension
ally and is not under the patients‘ control. Pain is of two types:-
Pain disorder associated with psychological factors and non
identifiable medical condition.
Psychological factors play a major role in the onset, severity,
exacerbation or maintenance of the pain.
Pain disorder associated with psychological factors and also
general medical condition. Both these factors have important role
in the onset, severity, exacerbation or maintenance of pain.
DIFFERENCE BETWEEN
   PSYCHOSOMATIC
   DISORDERS AND
    SOMATOFORM
     DISORDERS
1.psychosomatic disorder causes damage in
physical level,somatoform disorder does not.
2.psychophysiological       disorder    invole
internal     organs     ie;lungs,viscera,heart
etc.somatoform disorder invole bodily
           organs-hands,eyes,voice
3.patients           suffering            from
psychophysiological disorders are anxious
about their symptoms and feelings.
-individual suffering from somatoform
disorder are attention seeking,but not
anxious about their symptoms.they show no
feeling.
     THEORIES OF
   DEVELOPMENTS OF
PSYCHOPHYSIOLOGICAL
DISORDERS ETIOLOGICAL
      FEATURES
Experimental and clinical evidence
   has shown that the emotional
disturbances could be responsible
as predisposing, precipitating and
perpetuating factors in this illness.
 Several etiological theories have
         been postulated.
1) NEUROENDOCRINE
     THEORIES:
    the autonomic nervous system influences and is influenced by
both, other parts of the nervous system and the endocrine glands.
Complex inter relation of these various structures have been
postulated to explain the translation of the conflicts arising from
the problems of the every day living into abnormal physiological
functions and tissue damage. The hypothalamus being the centre
for the sympathetic and parasympathetic nervous activities is of
central importance In these feed back circuits.
    It is postulated that emotional disturbances acting through the
hypothalamus affect the sympathetic and parasympathetic
nervous system, which results in alteration in the structure of the
viscera to which these systems innervate.
         The imbalance of the sympathetic and the parasympathetic
nervous activities would alter the function of the viscera.
         The end result of all these change reactions would be the
revitalization of the organs. Eventually the organ becomes more
susceptible to external and internal stimuli.
2.ORGAN SYSTEM WEAKNESS;
weakness of a specific organ system is largely as
a result of genetic influence or prior damage of a
given system.eg; a person may be othervise
healthy may have a poor respiratory system.such
individuals are more likely to develop bronchial
asthma.
3.PSYCHOANALYTICAL                                     THEORY
According to this theory the basic underlying defect is the
weakness of the ego, which help an individual to face the realities
of                                                               life.
                 The development of both the ego and the
personality of the person takes shape mainly during the first few
years of life.teh future pattern of behavior are laid down during the
formative                                                      years.
                 That individual who suffers from psychosomatic
disorders certain infantile residues persists in later years.
Whenever such individual faced with stress of later life which they
cannot cope with adequately, these stress leads to psychological
or physiological regression to these infantile or immature patterns
of functioning resulting in the development of psychosomatic
                                illness.
This point is explained in the work of Alexander and dunbar.
              According to this concept- psychophysiological
disorders are symbols of unsolved unconscious conflicts and
                              frustration.
Eg; unsolved dependency leads to the development of fear
4.BEHAVIORAL THEORIES
Lechman pointed out that psychosomatic disorder is a learned
disorder.5 methods of learning process which leads to specific
symptomatology.
1.THE ROLE OF STIMULUS SUBSTITUTION THEORY- if a person
respond to neutral stimuli associated with one action producing
stimuli, soon the patient learns to respond to neutral stimuli.
          Eg; while it is raining,a child is frightened not by raining but
by lightning and thunder outside.however on subsequent occasion
even slight raining may lead to fear reaction in the absence of
thunder and lightning.
2.THE ROLE OF EMOTIONAL REINTEGRATION
          A single component in the stimulus situation which is earlier
associated with a complex pattern of emotional reaction may itself be
effective in producing the total complex pattern of emotional
reactions.eg; a boy fell into a river while fishing and was completely
drowned.from this single stimuluspeople fishing or sight of that bridge
serves to revive emotional reactions associated with earlier event.
3.THE    ROLE OF STIMULUS GENERALISATION
        eg;swimming in water may evole emotional
reaction that the boy felt after falling in the icy water.
4.ROLE OF SYMBOLIC STIMULI;stimuli in the personal
history of the individual represent effective emotion
provoking                                          stimuli.
         Eg;the word ‘rape’ may provoke strong
emotional reactions in a woman who has been sexually
                      assaulted.
5.THE           ROLE              OF            IDEATION
organismic affections of stimuli in terms of cns
manifestation, may persists in the form of thoughts or
ideas.eg;an individual may think about an emotional
event may feel associated emotion.(criticized by an
employer may feel anxiety)
 5.DIATHESIS STRESS THEORY


• IT means psychological or physiological
  predisposition.diathesis when associated
  with stress is likely to develop a
  psychophysiological disorder in an
  individual.
TREATMENT     INVOLVED                                  FOR     A
PSYCHOSOMATIC                                            DISORDER
         Increasingly doctors are recognizing the importance of dealing
with psychological and social factors in relation to physical disease.As
a result,many doctors now try to deal with the whole person. This
means taking all these factors into consideration. By doing this, it is
important to realize that the doctor is not playing down or ignoring the
physical disease.Many people with so called psychosomatic disorders
feel that their doctor does not take them seriously.They feel that the
doctor believes that it‘s all in the mind.The doctor will always attempt to
treat the physical illness with appropriate medical treatment if
necessary.But he will also be interested to understand more about the
person who has the illness.This will inturn help him and the person to
understand the illnessbetter.Sometimes it is helpful to look at the whole
lifestyleof the person involved.This may require lokking at how the
stress is involved.This may require looking at how the stress is dealing
with,teaching techniquesfor stress management, as well as examining
factors such as diet and exercise.
1.PSYCHODYNAMIC APPROACH IN THE
         TREATMENT OF
 PSYCHOPHYSIOLOGICAL DISORDER
• suggested by KARASU-says that effectiveness
  of this therapy depends on the patints
  preparation for the therapy.
• First step _ health alliance where the therapists
  builds trust in the patient by being supportive.
• 2nd step –therapist become more reliable and
  trust worthy.at this stage actual therapy may
  begin.this process is time consuming.ie;6-7
  years.
• KELLNER –says that this approach is effective
  in diseases like peptic ulcer,asthma and
  migraine and not inhypertension and ulcerative
  colitis.
            HYPNOTISM;
• Success of treatment depends on
  individual rather than disease.ie if the
  person has high hypnotic ability hypnosis
  can be effective.hypnosis directly influence
  autonomic nervous system functioning.
• Traditional psychotherapy
  approach;especially in ulcerative
  colitis(they are overly dependent and
  symbiotic in nature)
 II. BEHAVIORAL APPROACHES
         TO TREATMENT
• -to modify the environmental
  contingencies
•          -reinforcement like special
  attention or over protection is totally
  withdrawn.
•          -reinforced with rewards.
           BIOFEEDBACK

• Certain instruments which will inform the
  patient about the psychophysiological
  processes and then he is taught to bring
  them under voluntary control.
• Biofeedback technique-individual can
  control blood pressure,skin
  temperature,muscle tension etc.
  iii.MEDICAL APPROACHES
• -HOMOEOPATHIC-according to Hahnemann
  §225,corporeal diseases originating from emotional
  causes such as continued anxiety,worry
  vexation,wrongs and frequent occurrence of great
  fear and fright.these are called psychosomatic
  disorders.
•       Treatment is mentioned in§ 226 that by meas
  of psychical remedies such as display of
  confidence,friendly exhortations,sensible advices
  and often by a well disguised deception be rapidly
  changed into a healthy state of mind.
•       But the fundamental cause in these cases is
  also a psoric miasm.so the seemingly cured patient
  should be subjected to a radical antipsoric treatment
• iv.SPECIFIC DISEASES
• ASTHMA;-if emotional factors-
  psychotherapy or hypnosis is used.
• MIGRAINE;-biological and psychological
  approaches are used in the treatment.
• AFTER TREATMENT FOR A
  PSYCHOSOMATIC DISORDER
• The reasons that the illness arose are often
  complex and not easy to deal with.They can be
  confusing for the doctor as well as the
  patient.Time is required to allow the
  understanding if healing is to take place.There is
  no quick and easy answer.During the course of
  treatment the patient may feel that he is not
  being understood. It is important to share these
  feelings with the therapist or doctor.
• EFFECTS ON FAMILY OF A
  PSYCHOSOMATIC DISORDER
• People with psychosomatic disorders need
  the support and understanding of the
  family and friends. Nospecial expertise is
  required. A person who will listen and
  provide support at times of crisis is all that
  is required.
CAUSES OF DEVELOPMENTS OF
  CERTAIN PSYCHOSOMATIC
        DISORDERS
                        1.PEPTIC ULCER;
One of the most common psychosomatic disorder found among
the executives and those staying in urban areas.characterised
by the presence of crater like holes in the lining of the stomach
or duodenum due to excess of acid and pepsin in gastric juice.
CAUSES OF ULCER;there is biological predisposition towards
      high level of pepsinogen secretion,which is genetically
   aquired.ie;people with hypersecreting stomach&people with
 marked individual difference in pepsinogen level even at birth.
  Those who develop ulcer usually have stressful life evevents-
 leads to the development ulcer.eg;separation from loved ones
                        especially parents.
    Psychological and intrapsychic factors are important in the
 development of ulcers.Franz Alexander suggested that-unmet
dependency needs anger oriented reaction,persistent conflict &
        repressed hostility leads to developments of ulcer.
• 2.TENSION HEADACHE AND MIGRANE HEADACHE;
• 90% of headaches have emotional cause.tension
  headache is a disorder of musculoskeletal system and
  migraine is a disorder of cardiovascular system.
• MIGRANE;Inherited genetic predisposition causes
  changes in the vascular system-causes dialatation of
  extracranial arteries.when individuals are unable to cope
  with the personal function& conflict they develop
  increased intracranial pressure leading to
  vasoconstriction and migraine.
• 3.ESSENTIAL HYPERTENSION
• Physiological predisposition is the chief cause.individuals
  with hyperactive sympathetic nervous system increases
  blood pressure.also there is some predisposition to
  certain personality traits;ie inhibited hostile tendencies or
  chronic feeling of hostility leads to hypertension.
         4.CORONARY HEART DISEASE;
 Certain individuals are more prone to CHD due to
  situational challenges they face.they are called
    typeA individuals.(concept by Friedman and
   Rosenmann)they are emotional achievement
               orinted,competitive,time
conscious,perfectionistsand are always functioning
above their physiological baseline are predisposed
             to coronary heart disease.
  According to Lipowski-combination of biological
  andpsychosocial factors are responsible for the
              development of CHD.
END